LIU POST

DEPARTMENT OF NUTRITION/DIETETIC INTERNSHIP

PATIENT MANAGEMENT REPORT (PMR)


Interns Name: Laryssa Grguric Date: 4/24/14
Rotation/Facility: South Shore Dialysis Center Preceptors Signature:


Part I:
A. Patient Information:

Initials: I.R. Occupation: Disabled/unemployed; was a
teachers aide
Admission Date: 3/14/14
(re-initiation of HD)
Gender: F Socioeconomic Status: Middle Class Marital Status: Divorced
Age: 48 Residence (Home or LTC): Home apartment Ethnicity: Hispanic


B. Diagnosis: Stage 5 CKD (anuric)
HD Rx:
Access: L permacath / HD Rx: 4 hours, BF: 300, 3K+ bath

C. Medical Problem List: Failed kidney transplant (1999) resulting from transplant glomerulopathy,
anorexia, hyperlipidemia, hyperthyroidism

D. Medical/Social Hx:

Medical Hx:
- Stage 5 CKD /ESRD
- HTN
- DM Type 2 c! diabetic neuropathy
- PAD
- Gout

Social Hx:
- On disability
- Wheelchair bound
- Reports good social support system from family (lives c! son & her mother)
- On transplant list

E. Physical/Anthropometric Data (if available):

Date: 4/24/14 Height: 61 UBW: %UBW:
Dry Wt: 36.5 kg SBW: 54 kg %SBW: 68% BMI: 15
Pre Wt: 37.7 kg Post Wt: 36.5 kg IDWG: 1.2 kg Adj BW: 67.6 kg

Note any findings from physical assessment:

F. Pertinent Laboratory Data (Monthly Labs):
List
Normal
Values
Norm
( 12.1-
15.6 ) )
Hgb
Norm
(34-
45%)
Hct
Norm
(78-93) )

MCV
Norm
(35-5.0) )

Alb.
Norm
( 8.4-
10.2)
Ca++
Norm
( 2.3-
4.3)
Phos
Norm
( 8-23 )

BUN
Norm
( 0.4-1
1.2)
Creat
Norm
(136-
144)
Na+
Norm
( 3.5-
5.0)
K+
Norm
( 70-
109)
Glucose
Norm
( 18-38 )

Pre-Alb
Norm
( 4.5-6 )

A1c
Date: 3/6
La Lab Value
8.9!

28.8! 83.6
WNL
2.4! 7.9 !
Cor:
9.2
2.9
WNL
23
WNL
2.6" 133
WNL
4.3
WNL
200" N/A 6.5%
Date: 4/10
Lab Value
9.1! 30.8 ! 88.3
WNL
2.3 ! 8.3!
Cor:
9.7
2.1
WNL
14
WNL
1.96" 138
WNL
4.5
WNL
207" 8.6 ! 6.8%

Additional Labs from 4/10:

List
Normal
Values
Ferritin
(2-110)
TIBC
(211-
406)
Transferritin
Sat
(22-52%)
URR
(>65%)
Kt/V
(<1.2)
Date: 4/10
Lab Value
1806" 88! 53% " 79%
WNL
1.79
WNL

GFR on 3/6: 21 mL/min/1.73 m
2
*
GFR on 4/10: 30 mL/min/1.73 m
2
*
*pt on dialysis


Part II: Medical Problems, Laboratory Tests and Medications (address each of the three
areas (A-C) listed under guidelines; duplicate as many pages as necessary of this sheet)
Reference your medical text findings using APA (author, year, page number).

Summary of Medical Text Findings Comparison of Patient to Text
A. Pertinent Medical Problems: include
background of each disease from text
and include medical nutrition therapy
(MNT) for each; include kcal and
protein recommended if noted;
highlight information that can relate to
this patient.
A. Pertinent Medical Problems: include
how each disease is affecting patient;
what treatments patient is receiving;
therapeutic diet PTA and diet order in
hospital; how does the kcal/protein
recommended for each disease translate
for this patient? Do not complete an
assessment.
A) Chronic Kidney Disease

Also called Chronic Renal Failure. Chronic
Kidney Disease (CKD) is a progressive
deterioration of renal function (McMillan,
2011, 2442). CKD causes permanent damage
and eventually leads to end-stage renal disease
(ESRD) also known as CKD Stage 5. It may
result from any cause of renal dysfunction but
the most common is diabetic nephropathy
followed by hypertensive
nephroangiosclerosis (McMillan, 2011,
2442). Diabetic nephropathy is the leading
cause of ESRD (Escott-Stump, 2012, 861).
Metabolic syndrome is a large and growing
cause of renal damage (McMillan, 2011,
2442). About 23 million people have CKD c!
moderately or severely reduced glomerular
filtration rate (GFR) (Escott-Stump, 2012,
860). Fifty percent of patients with CKD
also have DM (Escott-Stump, 2012, 864).

Sx of CKD include: anorexia, nausea,
vomiting, stomatitis, dysguesia, nocturia,
lasstitude, fatigue, pruritus, decreased mental
acuity, muscle twitches, muscle cramps, water
retention, undernutrition, GI ulceration, GI
bleeds, peripheral neuropathies and seizures
(McMillan, 2011, 2442).

! renal function interferes c! the kidneys
ability to maintain fluid and electrolyte










Hx of DM/HTN











! appetite since failed transplant




Hx of neuropathy




homeostasis. The ability to concentrate urine
occurs early on in the disease and is followed
by ! in ability to excrete P, acid and K. Soon,
the ability to dilute urine is lost and urinary
volume does not differ c! " or ! fluid intake
(McMillan, 2011, 2443). Na+ and water
balance is maintained by " fractional excretion
of Na+ and normal fluid intake due to thirst.
Therefore, hypervolemia does not occur unless
dietary intake of Na+ or water is restrictive or
excessive (McMillan, 2011, 2443). K+ levels
" when kidney failure becomes more
advanced. K-sparing diuretics, ACE
inhibitors, beta-blockers, NSAIDs,
cyclosporine, tacrolimus or angiotensin II
receptor blockers may " K in sooner in the
progression of disease (McMillan, 2011,
2443). Ca+, parathyroid hormone, vitamin D
metabolism and renal osteodystropy can occur
resulting in hypocalcemia, hyperphosphatemia,
" or ! bone turnover. Osteopenia or
osteomalacia may also occur (McMillan, 2011,
2443).

Moderate acidosis and anemia are often
evident. Anemia in CKD is normochromic-
normocytic: Hct 20-30% and is caused by !
erythropoietin. CKD pts may also be
deficient in Fe, folate, and vitamin B
12

(McMillan, 2011, 2443).

CKD is suspected when creatinine " but initial
steps include determining if renal insufficiency
is acute, chronic or acute superimposed on
chronic. Testing includes urinalysis,
electrolytes, BUN, creatinine, phosphate,
Ca+ and CBC (McMillan, 2011, 2443).

Staging of CKD:
Stage 1: GFR ! 90 mL/min/1.73 m
2
(normal)
plus albuminuria or known structural or
hereditary renal disease
Stage 2: GFR 60-89 mL/min/1.73 m
2
Stage 3: GFR 30-59 mL/min/1.73 m
2
Stage 4: GFR 15-29 mL/min/1.73 m
2

Stage 5: GFR < 15 mL/min/1.73 m
2












Pt Rxd Lasix













Hct 28.8, 30.8

Vit B12 deficiency






Regularly monitored during dialysis (monthly)






GFR 21, 30; pt on dialysis with creatinine
clearance; pt is stage 5 (ESRD)


(McMillan, 2011, 2443).

Progression of the disease is determined by
degree of proteinuria (McMillan, 2011, 2443).
The kidney plays a role in regulation of blood
pressure (BP) through the renin-angiotensin
system (Escott-Stump, 2012, 860). HTN and
other underlying disorders are associated
with more rapid progression (McMillan,
2011, 2443). Weight loss and anorexia are
associated with mortality (Escott-Stump,
2012, 860).

Dialysis is an artificial filtering of blood by a
machine. There are two types: hemodialysis
(HD) and peritoneal dialysis (PD). Chronic
long-term dialysis can lead to malnutrition if
not carefully monitored (Escott-Stump, 2012,
875). Toxins accumulate with renal failure,
which can cause a decrease in appetite. Pts
may also experience pica which can further
decrease PO intake (Escott-Stump, 2012, 875).

a) MNT for CKD

The primary goal in MNT for CKD is to
manage sx such as edema,
hypoalbuminemia and hyperlipidemia,
decrease the risk of progression to renal failure
and maintain nutritional stores (Wilkens et al.,
2012, 810).

A renal patient needs a detailed nutrition
assessment including Subjective Global
Assessment (SGA) to monitor physical
changes such as weight changes and changes in
muscle mass, diet history and gastrointestinal
symptoms. Fluid shifts related to edema
may cause difficulty in tracking weight
losses (Escott-Stump, 2012, 860).

Following a HTN diet, such as the DASH diet,
low in sodium c! regular exercise can help to
reduce BP to goal of <130 mm Hg systolic and
<80 mm Hg diastolic. Blood glucose should
be under control; aim for HbA1c " 7%. DM





H/o HTN



BMI = 15 c! poor appetite



Pt is on hemodialysis.













IDWG = 1.2 kg (WNL)
Alb 2.4!, 2.3!, h/o of hyperlipidemia





Moderate to severe temporal wasting evident
with severe prominence of clavicles.



IDWG as above.






pts may have to initiate carbohydrate
counting. All pts would benefit from
increased fruits and vegetables while limiting
processed foods (Escott-Stump, 2012, 869).

It is imperative to maintain or improve
nutritional status when possible. Aim to keep
serum albumin at 4.0 g/dL; <3.4 g/dL for those
on HD. A 10:1 ratio of BUN:creatinine is
desirable. Urinary creatinine doubles when
renal function is <50% (Escott-Stump, 2012,
868).
Energy requirements for nondialyzed patients
>60 years of age with GFR <25 mL/min need
35 kcal/kg/day. Those <60 years of age need
30-35 kcal/kg/day. Intake from carbohydrates
should be 50-60% (Escott-Stump, 2012, 869).
Pts on HD require 35 kcal/kg/day if they are
<60 years of age and 30-35 kcal/kg/day for
patients that are >60 years of age (Escott-
Stump, 2012, 877). If DM or heart disease is
present, limit fat to 30% of calories with
>10% of total calories from saturated fats
(Escott-Stump, 2012, 869).

In CKD stages 1-3, limit protein to 0.8-1.0 g
protein/kg IBW. Choose high-quality proteins.
In CKD stage 4 reduce protein with GFR <25
mL/min reduce protein to 0.6 g protein/kg
IBW/day (Escott-Stump, 2012, 869). A pt on
HD requires 1.2 g/kg/day with at least 50%
of high biological value protein (Escott-
Stump, 2012, 877).

Patients c! DM, HTN or edema should limit
their Na+ intake to 2.3 g/day (Escott-Stump,
2012, 869). When monitoring phosphorus and
K+, guidelines are based on CKD stage.
Phosphorus: Stages 1-2 limit 1.7 g/day. Stages
3-4 limit to 0.8-1.0 g/day. Phosphate binders
are recommended along with limited intake of
dairy: 1-2 servings/day (Wilkens et al., 2012,
812). K+: Stages 1-2 keep to >4 g/day. Stages
3-4: 2.4 g/day (Escott-Stump, 2012, 869).
Intake and K-depleting medication such as
diuretics can affect K+ level (Wilkens et al.,

Pt. is type 2 diabetic on insulin uses
carbohydrate counting to dose insulin.






Alb !









Pt is 48


H/o hyperlipidemia, HTN













H/o DM, HTN









2012, 812). Fluid intake should be restricted to
1L of fluid a day if pt is anuric (Escott-
Stump, 2012, 877)

Patients c! CKD are routinely recommended
to take a vitamin to replace water-soluble
vitamins lost. There are renal formulations
available (Wilkens et al., 2012, 812).

Not everyone requires a strict HD diet and
therefore, diet therapy should be
personalized to the patient based on his or
her needs (Escott-Stump, 2012, 860). Levels
of K and P should be monitored and diet
modified accordingly (Escott-Stump, 2012,
877). In diabetic patients, glycemic control
can no longer reverse progression of CKD and
instead more importance relies on control of
BP and protein restriction when appropriate
(Escott-Stump, 2012, 861).

B) HTN

HTN is defined as sustained SBP and DBP
greater than 140 and 90 mm Hg (Escott-Stump,
2012, 367). Pre-HTN is defined as SBP
between 120-139 mm Hg or DBP b/w 80-89
mm Hg. Stage 1 HTN (140 to 159/90 to 99
mm hg) is the most prevalent level seen in
adults this population is most likely to have
MI or CVA (Raymond & Couch, 2012, 758).
HTN risk increases with age and therefore is
prevalent in the elderly. HTN doubles risk for
heart attack, stroke, HF (Escott-Stump, 2012,
367). Essential HTN (HTN with unknown
cause) is prevalent in 90-95% of pt (Raymond
& Couch, 2012, 758).

HTN is asymptomatic until complications
develop (Bakris, 2011, 2067). Sx of HTN
include frequent headaches, impaired vision,
sob, nosebleeds, chest pain, dizziness, failing
memory, snoring, sleep apnea and GI distress
(Escott-Stump, 2012, 367).

Sleep apnea, drug-related causes, CKD,
Rx Lasix but pt is anuric, not likely excreting
K+



Pt is on Renavite




































Stage 5



Cushings syndrome, steroid therapy,
pheochromocytoma, reno vascular disease can
cause high BP (Escott-Stump, 2012, 368).
Lifestyle choices such as poor diet, smoking,
physical inactivity, stress, obesity can
contribute to HTN. Secondary HTN is a result
of another disease, usually endocrine in nature
(Raymond & Couch, 2012, 758).

If left untreated, HTN can lead to stroke, HF,
renal failure, MI, accelerated bone loss,
increase risk of fracture and LT memory
problems (Escott-Stump, 2012, 367).

b) MNT for HTN

For dietary tx of HTN, the DASH diet is
recommended. DASH is rich in fiber, includes
5-10 servings of fruit and vegetables a day and
non-fat dairy products. In comparison to BP
lowering medication, DASH significantly
reduced BP (Escott-Stump, 2012, 368). DASH
can reduce SBP 8-44 mg Hg. Sodium should
be limited to 2300 mg/day. If target BP is not
reached, sodium can be further decreased to
1600 mg/day. Reduction of sodium can reduce
SBP 2-8 mm Hg (Raymond & Couch, 2012,
762).

Fish oil rich in omega-3, antioxidants such as
vitamin C, folic acid, vitamin K, soy protein
and a Mediterranean style diet may also have a
positive effect in HTN tx (Escott-Stump, 2012,
368). Including physical activity of 30
min/day on most days can reduce SBP by 4-9
mm Hg Reducing ETOH to 2 drinks/day for
men and 1 drink/day for women can reduce
SBP 2-4 mm Hg (Raymond & Couch, 2012,
762).

By following DASH and including an exercise
regime, weight management can be achieved
and possibly reduce SBP by 5-20 mm Hg
(Raymond & Couch, 2012, 762).



H/o of anorexia; diet recall appears adequate






















Consistent with renal diet recommendations








Mediterranean Diet would have to have
limitations prn; can be " in K, Phos







Pt is physically limited




C) Gout

Gout is a collection of monosodium urate
crystals into tissue (, 2011, 350). The etiology
behind gout is unknown (McCarty, 2011, 354),
but gout can be induced by diuretics (Bakris,
2011, 2071). Accumulation, called tophi
(Winkler & Malone, 2012, 917) usually occurs
in and around joints and can cause recurrent
acute or chronic arthritis. Diagnosis is
determined by clinical criteria and presence of
crystals in synovial fluid (McCarty, 2011,
349). Tests performed include synovial fluid
analysis, serum urate level and x-rays
(McCarty, 2011, 351). Gout occurs more often
in men during middle age. If a pt under 30
develops gout, it is often more severe
(McCarty, 2011, 350).

Sx of gout include acute pain, tenderness,
warmth, redness and swelling in affected areas
(McCarty, 2011, 349.) Pain is often nocturnal.
The areas most affected is the
metatarsophalangeal joint of the great toe but it
can occur in the hip, shoulder, sacroiliac,
sternoclavicular or cervical spine joints.
(McCarty, 2011, 350). Another site for tophi is
the helix of the ear (Winkler & Malone, 2012,
917). Tx for gout includes anti-inflammatory
drugs, treating co-existing HTN,
hyperlipidemia and obesity and prevention of
further deposition of crystals by lowering
serum urate level (McCarty, 2011, 352).

c) MNT for Gout

Gout has been traditionally treated by a low
purine diet, but has since been replaced by
drugs, allowing the diet to treat gout to become
more liberalized (Gomez & Kaufer-Horwitz,
2012, 917). It is not recommended that pts
follow a balanced diet c! limited intake of
animal foods, alcohol, avoidance of foods
high in purine, fructose and non-complex
carbohydrates. Portion control should also be
emphasized. Weight loss and glycemic control





Rxd Lasix























+ Hx











Contraindicated renal pts need " HBV prot
sources; complex carb also contraindicated due
to " Phos


can help to improve gout. High fluid intake
(8-16 cups daily) should be encouraged to
help excrete uric acid and minimize kidney
stone formation. Foods high in alkaline such
as dairy, eggs, vegetable proteins, cherries and
coffee may be protective against uric acid build
up since the foods are alkaline in nature
(Gomez & Kaufer-Horwitz, 2012, 918).

D) Peripheral Artery Disease

Peripheral artery disease (PAD) can affect the
arteries, veins or lymph vessels. The most
common type of PVD is peripheral artery
disease (PAD). Prevalence increases with age.
In population of pts 70 years or older, 20% are
affected by PAD. Non-Hispanic blacks and
Mexican Americans are more affected than
other race or ethnic groups. Individuals with
PAD have a 6-7x greater risk of heart attack or
CVA (Escott-Stump, 2012, 377). Other risk
factors include HTN, DM, dyslipidemia,
cigarette smoking and obesity (Hallett, 2012,
2218). Artery occlusion occurs from a clot or
plaque formation that can lead to pain,
numbness or tingling in the lower extremities.
In others, difficult ambulation, gangrene and
potential amputation may occur (Escott-Stump,
2012, 377). Amputation is indicated for
uncontrolled infection, unrelenting rest pain
and progressive gangrene (Hallett, 2012,
2220).

Causes of PAD include smoking, arterial
embolism, obesity, DM, renal insufficiency,
poor circulation, atherosclerosis, dyslipidemia
and HTN (Escott-Stump, 2012, 377).

d. MNT for PAD

Pts will benefit from aggressive risk factor
modifications such as smoking cessation,
control of DM, dyslipidemia and HTN.
Exercise for 35-50 minutes 3-4x a week can "
symptom-free walking and improve quality of
life (Hallett, 2012, 2219).
Fluid res ~1200 ml




















+ Hx




















Pt currently has moderate glycemic control
evidenced by A1c 6.5%, 6.8%



Goals of MNT in PAD are to decrease
cardiovascular risk to reduce complications
such as angina, HF, MI, CVA, renal failure,
ulcerative disease and gangrene (Escott-Stump,
2012, 378). Pts who are overweight or obese
should undergo weight management therapy
using a low calorie diet high in fiber (Escott-
Stump, 2012, 378).

Serum vitamin D levels may be low and should
be corrected via supplementation. Diet should
also be high in vitamin E. Monitor serum tHcy
levels. If tHcy levels are elevated, " folic acid,
riboflavin, vitamin B
6
and B
12
. If warfarin is
used, monitor vitamin K foods and avoid: dong
quai, fenugreek, feverfew, excessive garlic,
ginger, ginkogo or ginseng (Escott-Stump,
2012, 379).

E. Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) is marked by
inadequate insulin secretion. While insulin
levels are high in Type 2, peripheral insulin
resistance and " in hepatic glucose production
make insulin available inadequate to normalize
glucose level (Crandall, 2011, 867). T2DM
accounts for 90-95% of all DM cases; many
undiagnosed (Franz, 2012, 678). Risk factors
include genetic and environmental factors,
older age, obesity (particularly
intraabdominal), physical inactivity, prior hx of
gestational DM, race and ethnicity (Franz,
2012, 678).

Blood glucose (BG) levels " after eating,
especially after a meal " in carbohydrate. BG
levels take longer to return to normal post-
prandial (Crandall, 2011, 867). Obesity and
weight gain contribute to insulin resistance.
Adipose tissue " plasma levels of free fatty
acids and adipocytokines impairing glucose
transport and muscle glycogen synthase
activity (Crandall, 2011, 868).















































Symptoms of DM during periods of
hyperglycemia include: frequent voiding of
urine, polyuria and polydipsia. Dehydration
may occur. Weight loss, nausea, vomiting,
blurred vision and a predisposition to bacterial
or fungal infections may occur (Crandall,
2011, 868).

Complications can result from poorly managed
DM, primarily vascular complications, that
can result in retinopathy, nephropathy and
neuropathy. Microvascular disease also impairs
skin healing that can compromise skin
integrity. HTN and dyslipidemia are
commonly seen in patients with DM
(Crandall, 2011, 869). Screening for
complications related to DM should become
five years after diagnosis including food
examinations, funduscopic examinations, urine
testing for proteinuria and microalbuminuria
and measurement of creatinine and blood lipid
profiles (Crandall, 2011, 871).

DM is diagnosed by monitoring fasting plasma
glucose levels but sometimes, oral glucose
tolerance testing (OGTT) is performed. OGTT
is more sensitive but less convenient and
therefore often only reserved for diagnosing
gestational DM (Crandall, 2011, 871). A
random glucose test > 200 mg/dL may be
diagnostic but it may also be influenced by a
recent meal and must be confirmed by repeat
testing if no other symptoms are present.
Hemoglobin (Hb) A
1c
allows for a
retrospective look at glucose levels over the
preceding 2-3 months. Urine glucose
measurement is no longer used (Crandall,
2011, 871).

Goals for glycemic control:
-BG 80-120 mg/dL during the day
-BG 100-140 mg/dL at bedtime
-HbA
1c
levels < 7% (Crandall, 2011, 872).

In the critically ill and hospitalized patients,
blood glucose levels should be ~110 mg/dL.













+Hx




















A1c 6.5%, 6.8%, WNL for DM pt











Pts in hospital will usually require IV insulin
(Escott-Stump, 2012, 548).

e. MNT for Type 2 DM

MNT for T2DM requires an individualized
approach. There is no single diabetic diet
but a diet prescription based on individual
needs and goals (Escott-Stump, 2012, 521).
Pts should be educated on self-management via
diet and self-monitoring of blood glucose
(SMBG) (Franz, 2012, 684). Diet should be
reduced in calories and fat, carbohydrate
counting or exchange lists with simple meal
plans, physical activity and behavioral
strategies should be incorporated in treatment
(Franz, 2012, 684).

Total carbohydrate intake eaten regardless of
the source is the primary determinant of
postprandial glucose levels (Franz, 2012, 684).
Carbohydrate should contribute to 45-65% of
total energy intake (Escott-Stump, 2012, 546).
Consistency in carbohydrate intake eaten at
each mealtime or snack can help to improve
glycemic control either solely by diet therapy,
or in combination with glucose lowering
medications or insulin regimens (Franz, 2012,
684). Carbohydrate counting considers 15 g of
carbohydrate to be 1 serving. Exchange lists
group foods into list depending on their
carbohydrate content. This method utilizes
symbols to identify foods high in fiber, fat or
sodium (Franz, 2012, 685). Protein should
contribute 15-20% of total calories if renal
function is normal. If the kidneys are
affected, protein restriction to 0.8-1.0 g/kg is
recommended (Escott-Stump, 2012, 546). Fat
can contribute 25-35% of total calories but
saturated fats should be restricted to 7-10%,
focusing on a higher intake of PUFAs and
MUFAs (Escott-Stump, 2012, 546). The
DASH diet principals are useful in planning a
DM diet plan, as it will help to manage HTN if
present and reduce NA+. Less than 2400 mg
Na+ is recommended (Escott-Stump, 2012,






Pt admits that once she received her kidney
transplant, she did not follow any restrictions
and completely liberalized her diet.



























Not indicated, pt is on HD
546).

Testing pre-meal and post-meal glucose levels
can help pts to make adjustments to their meal
planning (Franz, 2012, 685). These diet plans
are portion controlled and can lead to weight
loss. Moderate weight loss of 5-10% can !
hyperglycemia, dyslipidemia and hypertension
(Escott-Stump, 2012, 546).




Part II: continued

Summary of Medical Text Findings Comparison of Patient to Text
B. Medications: list medication,
indication, effect of food and drug
interactions relative to nutrition: factors
that can affect nutrition
intake/GI/vitamins, minerals and labs.
Reference
c) Medications: how is medication
affecting patient? Is patient
experiencing any side effects?
1) Heparin/Lovenox
Anticoagulant. May cause abdominal pain, GI
bleeding, constipation and black tarry stools.
Caution c! DM & ESRD. ! Platelets. " AST,
" ALT, " PT/INR (Pronsky, 2012, 154).

2) Epogen/Epogen Alfa
Recombinant human erythropoietin,
antianemic. Stimulates RBC production. May
need Fe, VitB
12
, or Fol suppl. ESRD- diet
compliance mandatory. Not c! Fe, VitB
12
or Fol
def anemia, hemolysis, uncontrolled HTN or
GI bleeding. Caution c! seizures or vascular
disease. N/V, diarrhea. "RBC, ! hemoglobin,
! hemocrit ! Fe, ! ferritin, ! transferrin
saturation, ! bleeding time. Monitor BP, renal
func, electrolytes, K, P, Fe studies, Vit B
12

(Pronsky, 2012, 122).

3) Lasix/Furosemide
Anti-hypertensive, diuretic (K-depleting).
Used for tx of edema associated with CHF,
renal or hepatic disease. Take on empty
stomach, food ! bioavailability, but may take
with food/milk if GI upset occurs. Avoid
natural licorice. Limit alcohol. ! BP with
possible hypotension. Lab values may indicate
! K, ! Mg, ! Na, ! Cl, ! Ca and " glucose
(Pronsky, 2012, 110).

4) Novolog/Insulin
Antidiabetic, hypoglycemic. Use c! diabetic
meal plan to balance carbohydrate c! doses. "
wt. Avoid ETOH. Large wt. gain " insulin
needs. ! Glucose, ! HbA1
c,
! K, ! Mg, ! P

Given due to PAD










Necessary for pt on HD







Pt not likely excreting thiamin (anuric)











Pt is Type 2 diabetic



(Pronsky, 2012, 167).

5) Cymbalta/Duloretine
Antidepressant, antianxiety, fibromyalgia
treatment. Analgesic for diabetic peripheral
neuropathy. ! appetite, ! wt, anorexia. Dry
mouth, nausea/vomiting, dyspepsia, gastritis,
constipation, diarrhea. Avoid ETOH.
Insomnia. " ALT, " AST, " CPK, " alk phos,
! glucose, ! na (Pronsky, 2012, 115).

6) Zyloprim/Allopurinol
Antigout, Xanthine Oxidase Inhibitor. Drink
2.5-3 L fluids/day to produce 2 L urine per
24 hr. Avoid large doses of Vit C. Taste
loss/changes, N/V, gastritis, abdominal pain,
diarrhea. Rare- Renal failure/insufficiency,
peripheral neuropathy. ! uric acid. " alk
phos, " AST, " ALT, " Bil, " BUN, " crea
(Pronsky, 2012, 27).

7) Norvasc/Amlopidine
Antihypertensive, antiangina, Ca channel
blocker. May take c! food to ! GI distress. !
Na, ! cal may be recommended. Avoid
natural licorice. No significant reaction with
grapefruit. Dysphagia, nausea, cramps. ! BP,
edema (Pronsky, 2012, 32).

8) CellCept/Mycophenolate
Immunosuppressant to prevent renal, hepatic
or cardiac transplant rejection. Used c!
cyclosporine & corticosteroids. Take Mg
suppl/antacid separate from drug. Dyspepsia,
N/V, GI hemorrhage, abdominal pain, diarrhea.
Caution c! severe ! renal func & GI disease
e.g. ulcers. Infection, chest pain, cough,
dyspnea, HTN, edema, headache, asthenia.
Anemia. ! or " K, " chol, ! P, " glucose, !
Mg, " BUN, " crea (Pronsky, 2012, 214).

9) Ecotrin (enteric coated)/Aspirin
Analgesic, Antipyretic, Antiarthritic, NSAID,
to prevent CVA/MI. Food ! rate of abs.
Insure adequate fluid intake/hydration. "



Hx of depression, neuropathy
! intake may be exacerbated







Contraindicated (1.2 fluid res)



May have exacerbated transplant failure?






Indicated for renal/HTN diet







Pt is on prednisone





+Hx
Pt has anemia, K WNL, " glu, BUN, creat
(may be exacerbated)





Contraindicated due to 1.2 L FR
foods high in Vit C & Fol c! " LT dose.
Avoid or limit natural products that affect
coagulation. Limit caffeine. Anorexia. N/V,
dyspepsia, black tarry stools. Avoid alcohol.
Caution c! diabetes. Not c! severe anemia,
severe ! renal or hepatic func. ! K, ! Fe, "
BUN, " crea. Rare anemia. High dose- "
or ! glucose. ! C-Reactive Protein.
(Pronsky, 2012, 44).

10) Zocor/Simvastatin
Antihyperlipidemic (to ! total & LDL chol or
TG) To prevent or ! risk or cardiovascular
events. Take s! regard to food. Avoid
grapefruit/related citrus. Avoid SJW. Nauesa,
dyspepsia, abdominal pain, constipation,
diarrhea, flatulence. Avoid alcohol. Caution
c! renal func. ! chol, ! TG, ! LDL, ! VLDL,
! CRP. Contains lactose (Pronsky, 2012, 156).

11) Phoslo/Calcium Acetate
Phosphate binder. Urinary acidifier (to reduce
renal calculi or treat UTI), phosphorus suppl.
Avoid Ca, Vit D suppl or salt subs. Caution c!
K suppl. Take Fe, Mg, Zn suppl or Al antacid
separately by 2 hrs. " thirst, " wt. N/V,
stomach pain, diarrhea. Consider ! K or !
Na diet. Caution c! ! renal func, cardiac
disease or severe ! hepatic func. Edema. !
Ca, " P, " K, " Na (Pronsky, 2012, 249).

12) Prednisone/Corticosteroid
Anti-inflammatory, immunosuppressant.
Diet ! Na, " Ca, " Vit D, " pro. May need
" K, " Vit A, C, " P. Ca-Vit D suppl c! LT
dose. Caution c! grapefruit/citrus. Limit
caffeine. " appetite, " wt. Pro catabolism.
Ca c! LT use. Avoid alcohol. Caution c! DM
- " glucose. Hypoalbuminemia. Caution c!
renal function. Edema, " BP, insomnia,
masking of infection, slow healing, diabetes.
Osteoporosis/necrosis, fractures, muscle
wasting. ! Na, ! K, ! Ca, " glucose.
(Pronsky, 2012, 92)


Hx of anorexia

Pt is a diabetic, anemic, ! renal function
" glu






@ risk due to HTN




ESRD






On IV Fe

" thirst may be difficult; pt on 1.2L FR
Pt req " K foods to help prevent hypokalemia


All WNL


Pt taking due to kidney transplant
Pt receives Hectorol during HD tx.


Pt has ! appetite, ! body wt

Alb 2.4!, 2.3!
Hx of HTN

Temporal wasting evident

Summary of Medical Text Findings Comparison of Patient to Text
d) Laboratory Tests: key tests and their
implications relative to patients
medical problems; include reasons for
increase and decrease for each lab.
Reference
C. Laboratory Tests: assess patients
laboratory values; refer to chart on first
page or use values from your facility;
note if any medications are affecting
lab values.
1. Mean Corpusal Volume: Norm (78-93)
" with megaloblastic anemia due to Fol or Vit
B12 def, liver disease, reticulocytosis,
myelofibrosis
Spurious with cold agglutinins.
! with Fe def anemia, hereditary,
spherocytosis, thalassemia minor, sideroblastic
anemia, Pyr-responsive anemia, lead poisoning
(Pronsky, 2012, p. 349).

2. Hemoglobin: Norm (12.1-15.6 g/dL)
" c! severe burns, polycythemia, shock
! c! anemia, blood loss, hemolysis, leukemia,
hyperthyroidism, cirrhosis, over hydration
(Pronsky, 2012, 346).

3. Hematocrit: Norm (34-45%)
" c! dehydration, polycythemia, CHF,
thalassemia, COPD, dehydration.
! c! anemia (<30), hyperthyroidism, cirrhosis,
many systemic diseases (eg. Leukemia, Lupus,
Hodgkins disease), HIV/AIDS (Pronsky,
2012, 346).

4. Albumin: Norm (3.5-5.0 g/dL)
" c! dehydration
! c! edema, hepatic disease, malabsorption,
diarrhea, burns, eclampsia, ESRD,
malnutrition, low pro intake, stress, over-
hydration, cancer (Pronsky, 2012, 340).

5. Calcium (Ca): Norm (8.4-10.2 mg/dL)
" c! cancer, hyperparathyroidism, adrenal
insufficiency, hyperthyroidism, Pagets
disease, prolonged immobilization, excessive
Vit D or Ca intake, LT use of thiazide
diuretics, respiratory acidosis, milk-alkali,
Chronic renal failure, granulomatous disease
! c! hypoaluminemia, elevated phosphorus,
alkalosis, diarrhea, hypoparathyroidism, sprue,

MCV WNL










Hgb 8.9 !, 9.1 !




Hct 28.8!, 30.8!








Alb 2.4!, 2.3!





Ca+ 7.9 ! 9.2 corrected; WNL
8.3 ! 9.7 corrected; WNL






osteomalacia, malabsorption, diarrhea, acute
pancreatitis, hypomagnesemia, starvation,
steroid use, vit D def (Pronsky, 2012, 342).

6. Phosphorus: Norm (2.3-4.3 mg/dL)
" c! ESRD, hypocalcemia, hypervitaminosis D,
bone tumors, Addisons, hypoparathyroidism,
acromegaly, sickle cell anemia
! c! hyperparathyroidism, alcoholism,
hypovitaminosis D, rickets or osteomalacia,
hyperinsulinism, acute gout, overuse of P
binders, Cushings syndrome, salicylate
poisoning, DM, alcoholism (Pronsky, 2012,
350).

7. Blood urea nitrogen: Norm (8-23
mg/dL)
" (azotemia) c! renal failure (> 50 = serious
impairment), shock, dehydration, infection,
DM, chronic gout, excessive pro
intake/catabolism, MI
! c! hepatic failure, malnutrition,
malabsorption, overhydration (excessive IV
fluids), pregnancy, SIADH (Pronsky, 2012,
342).

8. Creatinine: Norm (0.4-1.2 mg/dL)
" c! acute & chronic renal disease, muscle
damage, hyperthyroidism, muscle mass,
starvation, diabetic acidosis, high meat intake,
gigantism, acromegaly.
! c! pregnancy (Pronsky, 2012, 344).

9. Sodium (Na): Norm (136-144 mEq/L)
" (hypernatremia) c " dehydration & low fluid
intake, diabetes insipidus, Cushings
syndrome, coma, primary aldosteronism.
! (hyponatremia) c " edema, severe burns,
severe diarrhea/vomiting, diuretics, SIADH,
water intoxication, Addisons disease, severe
nephritis, starvation, hyperglycemia,
malabsorption, AIDS (Pronsky, 2012, 352).


10. Potassium (K): Norm (3.5-5.0 mEq/L)
" (hyperkalemia) c! renal failure, tissue damage,






Phos 2.9!, 2.1!


Common in ESRD; kidney cannot convert
inactive form of Vit D
Pt not currently on P binders






BUN 23, 14 WNL








Creat 2.6", 1.96"






Na+ 133, 138 WNL










K+ 4.3, 4.5 WNL
acidosis, Addisons, uncontrolled DM, internal
hemorrhage, overuse of K suppl, acute AIDS.
! (hypokalemia) with GI loss, IV fluid with
without K suppl, alcohol abuse, malabsorption,
malnutrition, diarrhea, vomiting, chronic stress
or fever, K depleting diuretic, steroid, estrogen
use, hepatic disease with ascites, excessive
licorice intake, renal disease (Pronsky, 2012,
351).

11. Glucose: Norm (70-109 mg/dL)
" c! DM, Cushings syndrome, Thi def,
acromegaly, gigantism, chronic hepatic
dysfunction, severe infections,
hyperthyroidism, pancreatitis, chronic hepatic
disease, prolonged physical inactivity,
chronic hepatic disease, prolonged physical
inactivity, chronic malnutrition, K def drugs
(eg corticosteroids), high dose
antihypertensives
! c! insulin overdose, islet-cell carcinoma,
bacterial sepsis, hypothyroidism, Addisons
disease, extensive liver disease, glycogen
storage disease, alcohol abuse, starvation,
vigorous exercise, pancreatitis, oral
hypoglycemic drugs (Pronsky, 2012, 345).

12. Ferritin: Norm (F: 12-150, M: 30-320
ng/mL)
" c! inflammatory diseases, chronic renal
disease, malignancy, hepatitis, Fe overload,
hemochromatosis
! c! Fe def anemia (Pronsky, 2012, 344).

13. Creatine clearance GFR: Norm (M: 85-
125, F: 75-115 mL/min)
" in acromegaly and burns
! in CHF, glomerular disease, eclampsia, gout,
multiple myeloma (Pronsky, 2012, 344).

14. Transferritin: Norm (22-52% mg/dL)
" c! inadequate Fe stores, Fe def anemia,
acute hepatitis, polycythemia, oral
contraceptive use, pregnancy.
! c! pernicious & sickle-cell anemia, infection,
cancer, hepatic disease, malnutrition, nephrotic











Glu 200", 207"
















Ferritin 1806"






GRF WNL; pt on dialysis





Transferritin 53% "




syndrome, thalassemia. Mild ! = 150-200.
Moderate ! = 100-150. Severe ! = <100
(Pronsky, 2012, 354).

15. Total Iron-Binding Capacity: Norm
(211-406 g/dL)
" c! Fe def, pregnancy, Fe def anemia
! c! chronic inflammatory states, Fe
overload, hemochromatosis (Pronsky, 2012,
353).





TIBC 88!


Part III: Nutrition History: Use hospital form or the form below.

A. A completed copy of the nutrition history form may be attached OR the following usual intake and
food frequency checklist should be completed.

Food Intake Pattern/Nutrition History
Directions: Record food intake over a 24-hour period including time eaten and portion sizes. Include all
food, condiments, alcoholic and carbonated beverages. If eating pattern differs each weekend or due to
different work shifts, record on a separate sheet. Food intake can be calculated by hand or computer.

Usual intake at Home on HD days:

Time Intake/Amt.
Breakfast: 1 pc whole wheat toast c! 1 tsp. butter and 1 cup coffee c! 2% milk (~2 tbsp)

Lunch: Tuna fish sandwich (1 can tuna, 2-3 tbsp regular mayo) on 2 pcs. whole wheat bread c!
onion
~2 cups homemade iced tea, lightly sweetened

Dinner: Cuban foods rice (~1/3 cup)/beans (1/4 cup), broiled fish/shellfish (e.g. 4 oz. salmon, 3-4
pcs shrimp), ~1 cup cauliflower (avoids green vegetables)

Snack: 2-3 tbsp. unsalted cashews
5 cubes Swiss Cheese (size 1)
1 cup 2% milk

Notes: Small portions, eats very little at meals. Pt reports that when she was a transplant recipient, she
was less of a controlled diabetic because she overindulged in foods since she was so restricted on a
renal diet.

Nutrient Analysis:





Iron (mg) 18.00 Do not exceed 45 mg *
Magnesium (mg) 320.00 Do not exceed 350 mg by supplement *
Phosphorus (mg) 700.00 Do not exceed 4000 mg *
Potassium (mg) 4,700.00
Sodium (mg) 1,500.00 Less than 2300 mg - lower for some
people +
Zinc (mg) 8.00 Do not exceed 40 mg *
Sources:
* Dietary Reference Intakes - For Adult 19-70 years, non-pregnant
+ 2010 Dietary Guidelines for Americans
Bar Graph Report
The Bar Graph Report displays graphically the amount of the nutrient consumed and compares that to the
dietary intake recommendations.
0 50 100 Percent Nutrient Value 150 DRI Goal
Basic Components
Calories 1,741.74 104 % 1,670.05
Calories from Fat 845.04 181 % 467.61
Calories from SatFat 346.33 230 % 150.30
Protein (g) 132.96 449 % 29.60
Carbohydrates (g) 87.45 38 % 229.63
Sugar (g) 18.26
Dietary Fiber (g) 8.85 38 % 23.38
Soluble Fiber (g) 1.45
InSoluble Fiber (g) 3.43
Fat (g) 93.89 181 % 51.96
Saturated Fat (g) 38.48 230 % 16.70
Trans Fat (g) 0.26
Mono Fat (g) 22.38 121 % 18.56
Poly Fat (g) 8.12 49 % 16.70
Cholesterol (mg) 319.39 106 % 300.00
Water (g) 898.13 33 % 2,700.00
Vitamins
Vitamin A - RAE (mcg) 543.64 78 % 700.00
Vitamin B1 - Thiamin (mg) 0.90 82 % 1.10
Vitamin B2 - Riboflavin (mg) 1.39 127 % 1.10
Vitamin B3 - Niacin (mg) 24.40 174 % 14.00
Vitamin B6 (mg) 1.27 97 % 1.30
Vitamin B12 (mcg) 11.83 493 % 2.40
Vitamin C (mg) 28.91 39 % 75.00
Vitamin D - mcg (mcg) 4.32 29 % 15.00
Vitamin E - Alpha 3.04 20 % 15.00
Folate (mcg) 225.10 56 % 400.00
Minerals
Calcium (mg) 1,557.26 156 % 1,000.00
Iron (mg) 7.88 44 % 18.00
Magnesium (mg) 315.92 99 % 320.00
Phosphorus (mg) 2,101.17 300 % 700.00
Potassium (mg) 3,341.20 71 % 4,700.00
Sodium (mg) 1,438.75 96 % 1,500.00
Zinc (mg) 11.85 148 % 8.00
Other
Omega-3 (g) 3.82
Omega-6 (g) 3.88
Alcohol (g) 0.00
Caffeine (mg) 2,682.67
Spreadsheet Report
The Spreadsheet shows all the values for all nutrients. Nutrients are displayed horizontally, with totals at the
bottom of the list.
Item Day Meal Amount Cals FatCal SatFatCal Prot (g)
Sun 04-
13-2014
Breakfast Bread, whole wheat, tstd, slice each 1 76.5 9.1 2.1 4.1
Butter, unsalted (USDA SR-21) tsp 1 34.0 34.6 21.9 0.0
Coffee, brewed w/tap water oz 8 2.3 0.3 0.0 0.3
Milk, 2%, w/add vit A & D (USDA tbsp 2 15.2 5.4 3.4 1.0
Lunch Fish, tuna, white, w/water, each 1 220.2 46.0 12.2 40.6
Dressing, mayonnaise, real tbsp 2 200.0 198.0 27.0 0.0
Onion, white, fresh, sliced (USDA tbsp 1 2.9 0.1 0.0 0.1
Tea, iced brew, bags (Lipton) oz 16 0.0 0.0 0.0 0.0
Dinner Rice, white, long grain, ckd cup 0.8 154.0 3.0 0.8 3.2
Beans, pinto, mature, ckd (USDA cup 0.2 61.1 2.5 0.5 3.8
Fish, salmon, pink, fillet, oz 4 169.0 45.1 7.2 29.0
Cauliflower, ckd, drained, 1" cup 0.5 14.3 2.4 0.4 1.1
Snack Nuts, cashews, oil rstd, tbsp 3 140.3 103.9 18.4 4.1
Cheese, Swiss, 1" cube (USDA oz 5 538.6 354.5 226.7 38.2
Milk, 2%, w/add vit A & D (USDA oz 8 113.4 40.2 25.6 7.5
Day Total -- 1741.7 845.0 346.3 133.0
Average Day Total -- 1741.7 845.0 346.3 133.0
Item Day Meal Carbs (g) Sugar (g) Fiber (g) Fib-S (g) Fib-I (g) Fat (g)
Sun 04-
13-2014
Breakfast Bread, whole wheat, tstd, slice 12.8 1.4 2.3 0.5 1.8 1.0
Butter, unsalted (USDA SR-21) 0.0 0.0 0.0 0.0 0.0 3.8
Coffee, brewed w/tap water 0.0 0.0 0.0 0.0 0.0 0.0
Milk, 2%, w/add vit A & D (USDA 1.4 1.4 0.0 0.0 0.0 0.6
Lunch Fish, tuna, white, w/water, 0.0 0.0 0.0 0.0 0.0 5.1
Dressing, mayonnaise, real 0.0 0.0 0.0 0.0 0.0 22.0
Onion, white, fresh, sliced (USDA 0.7 0.3 0.1 0.0
Tea, iced brew, bags (Lipton) 0.0 0.0 0.0 0.0 0.0 0.0
Dinner Rice, white, long grain, ckd 33.4 0.1 0.5 0.1 0.4 0.3
Beans, pinto, mature, ckd (USDA 11.2 0.1 3.8 0.3
TOTALS:
Kcals: 1741
PRO: 133 g / 532 kcal
CHO: 87 g / 348 kcal
Fat: 94 g / 845 kcal

% kcal from Pro/CHO/Fat:
PRO: 31%
CHO: 20%
FAT: 49%

REC % kcal from Pro/CHO/ Fat















Part IV: Nutrition Care Process: Assessment, Diagnosis, Intervention, Monitoring and
Evaluation (ADIME)

Assessment: include information about previous diet hx, physical assessment, medical problems,
supplement intake at home, socioeconomic problems, laboratory analysis, assessment of nutrient
hx (incorporate findings from your nutrient analysis in your assessment),
Assessment should include:
Subjective information:

Objective information (Dx, Medical Problems, Rx, Hx, Labs, Meds, Diet Order,
Anthropometrics):

Assessment: start your written assessment with nutrition Diagnosis (PES statement)


S: Pt. had received a kidney transplant in 1999 from Mt. Sinai Hospital that has since
failed; pt now requires initiation of HD. While pt was living with her transplanted kidney, she
admits that she did not follow any diet restrictions. After being restricted so long due to Dx of
DM and CKD, she wanted to liberalize her diet. Now, she reports that she is aware of her diet
and is a lot more adherent to the restrictions. However, at times, her appetite is poor and she eats
very small portions.
O: 48 y/o #. Dx: ESRD (CKD Stage 5). PMH: HTN, DM Type 2, PAD, gout, failed
kidney transplant due to glomerulopathy. Rx: Lovenox, Epogen, Lasix, Novolog, Cymbalta,
Zyloprim, Norvasc, CellCept, Ecotrin, Zocor, Phoslo and Prednisone. Ht: 61, Dry Wt: 36.7 kg,
IDWG: 1.2 kg, SBW: 54kg, %SBW: 68%, BMI: 15, Adj BW: 67.6 kg. Diet Rx: liberalized diet
secondary to low K, Phos levels. Labs: (3/6/14) Hgb 8.9!, Hct 28.8!, MCV 83.6 WNL, Alb
2.4!, Ca++ 7.9! corrected 9.2 WNL, Phos 2.9 WNL, BUN 23 WNL, Creat 2.6 ", Na 133 WNL,
K+ 4.3 WNL, Glu 200", A1
c
6.5% WNL for DM Type 2. (4/10/14): Hgb 9.1 !, Hct 30.8!,
MCV 88.3, Alb 2.3 !, Ca++ 8.3! corrected 9.7 WNL, Phos 2.1 WNL, BUN 14 WNL, Creat 1.96
", Na+ 138 WNL, K+ 4.5 WNL, glu 207", Pre-Alb 8.6!, A1c 6.8% WNL for Type 2 DM,
Ferritin 1806", TIBC 88!, Transferritin Sat 53%, URR 79% WNL, Kt/V 1.79 WNL. GFR
(3/6/14) 21 WNL, (4/10/14) 30.
A: PES: Inadequate energy intake related to increased nutrient needs due to ESRD+HD,
reported decreased appetite and a decreased ability to consume sufficient energy due to physical
limitations evidenced by BMI of 15, dietary restrictions related to DM/ESRD and diet recall
revealing less than adequate energy intake.
Calorie needs 30-35 kcal/kg using Adj BW of 67.6 kg (secondary to ! wt) 2030-2370
kcal/daily. Current usual intake evidenced by 24-hour recall shows intake of ~1741 kcals: 85%
of EEN. Protein needs for CKD Stage 5 are 1.2 g/kg; using Adj BW protein needs ~81 g daily.
Current dietary intake is adequate in protein: 133 g (165% of needs). Fluid restriction is 1.2L.
Na+ should be limited to 2-3 g daily. Current Na intake is 1.4 g, well under restriction. Phos/K
are not currently restricted due to levels WNL. Physical assessment reveals moderate to severe
temporal wasting with severe prominence of clavicles. No physical s/s of dehydration are
evident.
Due to ! H&H and ! MCV, Fe deficiency anemia is likely and may be related to
ESRD+HD. ! alb could be related to ! protein intake and is reflective of chronic inflammatory
state evident in ESRD. " glu also could be related to Lasix Rx and physical inactivity as dietary
recall does not reflect " CHO & kcal diet.










Part IV: Nutrition Care Process continued (Intervention, Monitoring and Evaluation)
There may be only one goal or there may be multiple goals.

Measurable Goals of Nutrition Care Specific Plans (Intervention): include
information highlighted from text and MNT in
Part II A if applicable to this patient.

Goal 1:
" H&H and MCV to WNL
Plan 1:
Continue IV Fe (Venefer) and Epogen;
recommend " Epogen dosage

Goal 2:
Maintain glucose between 80-120 mg/dL

Plan 2:
Encouragement of self monitoring blood
glucose levels to better determine insulin
dosage

Goal 3:
0.5-1 lb. weight gain per week

Plan 3:
-Encourage " portions
-Addition of snacks to daily meal regimen
-Counseling on " kcal choices: addition of
sauces/gravies, etc.




















References

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th
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