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DIET 3255 Manchester Memorial Hospital

ADIME #2
Emily Taylor

ASSESSMENT (5 points)

Patient Initials: HK
Gender: Female
Age: 82
Admission date: 3/31/17
Date Seen: 4/6/17

Admission Diagnosis:
Acute on chronic kidney failure
o AKI caused by acute tubular necrosis
o Possibly secondary to diuretic use

Treatments/Therapies/Alternative Medicine:
Renal ultrasound
o Showed increased marked atrophic changes of the right kidney
IV fluids
Cessation of diuretic use
Tunneled dialysis catheter placement
Hemodialysis
Erythropoietin supplementation

Past Medical History:

CKD, stage IV
Chronic anemia
CHF
o Note: patient had been discharged on 3/28/17 after hospitalization for acute on
chronic CHF, with shortness of breath and leg swelling. Patient was treated with
Lasix (diuretic therapy) and given a fluid restriction. Doctors note that AKI was
likely secondary to this diuretic therapy.
Squamous cell skin cancer to left food, s/p excision
CAD, s/p stent placement
Htn
T2DM
Hypercholesterolemia
Obstructive sleep apnea (on CPAP)
Peptic ulcer disease secondary to Plavix

Anthropometrics:
HT: 66 in
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WT: 195 lbs

IBW: 130 lbs
%IBW: 150%
UBW: 191 lbs
%UBW: 102%
BMI: 31.6 (Class I obesity)
Weight Changes: Slight weight change (+4 lbs) since admission. Difficult to determine cause
of changes because dialysis nurse reported that they were unable to get a dry weight for HK yet
because she was only on her third dialysis treatment.

History of Weight Changes:

HK reported some intentional weight loss in the past year, as she reported weighing 222 lbs last
year and reported that she was 191 lbs prior to admission.

Nutritional Requirements: (5 points)

Kcal Mifflin St. Jeor: 1639 kcal
Calculations:
Female: REE = [10 X wt (kg)] + [6.25 X ht (cm)] [5 X age (yrs)] 161
REE = [10 X 88.7] + [6.25 X 168] [5 X 82] 161
REE = 1366 kcal
X 1.2 (activity factor: sitting, lying all day) = 1639 kcal
Kcal/kg: 1477 kcal
Calculations:
25 kcal/kg IBW
59.1 kg X 25 kcal/kg = 1477 kcal
Protein gm/kg: g protein
Use 1.2-1.3 g protein/kg IBW for hemodialysis.
Calculations:
59.1 kg X 1.2 g/kg = 71 g
59.1 kg X 1.3 g/kg = 77 g
Fluid: 1600 mL
Method: 1 mL/kcal intake
Note: fluid restriction of 1500 mL lifted with initiation of hemodialysis treatment.

Diet Order: Renal controlled (4/3/17)

Previous Diet Orders:
Renal controlled (4/1/17)
o 50 g protein restriction
o 1500 mL fluid restriction
Cardiac (3/31/17)
Assessment of Appropriateness of Diet Order: Diet order should be changed to renal
controlled dialysis, which is high protein, 2 gram sodium, and 2 gram potassium. However, the
renal controlled dialysis diet includes a fluid restriction, while the renal controlled diet does not.
This would be counter to the decision by the medical team to lift her fluid restriction. This
decision makes sense because HK now has dialysis treatment to help regulate her fluid balance.
Dialysis allows liberalization of the diet in terms of fluid and protein because it removes
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nitrogenous wastes from the blood and regulates fluid balance by adding or removing
electrolytes.

Biochemical Data: (5 points)

Lab Date Normal Patients Interpretation Explanation

Name Range result
Na 4/6/17 136-145 136 Normal Electrolyte is balanced,
likely due to hemodialysis
treatment.
K 4/6/17 3.5-5.1 4.3 Normal Electrolyte is balanced,
likely due to hemodialysis
treatment.
Cl 4/6/17 98-107 96 Normal Electrolyte is balanced,
likely due to hemodialysis
treatment.
BUN 4/6/17 7-18 46 High Indicates that the kidney is
not effectively clearing
nitrogenous wastes,
consistent with dx of stage
IV kidney disease.
Continued treatment with
hemodialysis is needed to
bring BUN within normal
ranges.
Creatinin 4/6/17 0.550- 3.95 High Indicates that the kidney is
e 1.300 not effectively clearing
nitrogenous wastes,
consistent with dx of stage
IV kidney disease.
Continued treatment with
hemodialysis is needed to
bring creatinine within
normal ranges.
Glucose, 4/6/17 74-100 94 Normal Indicates that DM is under
serum control and that patient is
not in acute stress.
A1C 9/23/15 4.0-5.6 5.2 Normal Indicates that DM is well-
controlled. Has not been
tested recently because pt
had normal A1C values at
every testing since 2011.
RBC 4/6/17 4.0-5.4 2.33 Low Due to chronic anemia
secondary to chronic
kidney disease. Kidney has
impaired ability to produce
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EPO.
Hgb 4/6/17 12.1-15.7 6.9 Low Due to chronic anemia
secondary to chronic
kidney disease. Kidney has
impaired ability to produce
EPO.
Hct 4/6/17 36-46 21.0 Low Due to chronic anemia
secondary to chronic
kidney disease. Kidney has
impaired ability to produce
EPO.
Albumin 4/6/17 3.4-5.0 3.2 Low Could be due to losses of
protein in the urine
because of kidney disease
and/or inadequate protein
intake.
Calcium 4/6/17 8.5-10.1 8.2 (8.8 Low, but normal Corrected using albumin
corrected corrected value. Because calcium
) falls into normal ranges
corrected, supplementation
is not needed.
Iron 3/6/17 50-170 79 Normal Indicates that anemia is
not due to iron deficiency.

Ferritin 3/6/17 8-252 73 Normal Indicates that anemia is

not due to iron deficiency.

Is and Os
Date 24-hr Fluid Balance (mL)
4/6 +230
4/5 +890
4/4 +210
4/3 +1584
4/2 +1200
4/1 +990
Significance: Water retention due to rehydration with IV fluids. Dry weight should be taken once
appropriate.

Medications: (5 points)

Name Purpose Side Effects Nutritional Concerns

Zinc sulfate MINERAL Long term excess Take 1 hour before meals
SUPPLEMENT supplementation or 2 hours after meals. If
may cause Cu GI upset occurs take with
deficiency or food, but not high fiber or
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anorexia. Metallic phytate food. Take zinc at

taste, dyspepsia, least 2 hours apart from
N/V, abdominal Cu, Fe, Ca supplements
pain, diarrhea. or food high in bran fiber
Transient decrease or P rich foods (such as
in HDL with milk products) or phytate.
excessive intake.
Given for wound healing
on left foot. Should be
discontinued as soon as
the wound is healed
because of risk of Cu
deficiency.
Heparin ANTICOAGULANT N/V, abdominal Monitor serum K.
pain, GI bleeding,
constipation, black
tarry stools.
Caution with
diabetes and ESRD
hyperkalemia.
Atorvastatin ANTIHYPERLIPIDEMIC Nausea, dyspepsia, Decrease fat and
(HMG-CoA reductase abd pain, cholesterol, decrease
inhibitors) constipation, calories if needed.
diarrhea, Caution with
flatulence. Edema. grapefruit/related citrus.
Albumen or blood
in the urine.
Lactulose syrup To treat increased N/V, belching, High fiber with 1500-
AMMONIA LEVEL (To cramps, diarrhea, 2000 mL fluid/day to
prevent or treat portal- flatulence. prevent constipation. D
systemic encephalopathy) not take with antacids,
Mg or Ca supplements.
Caution with diabetes
can cause increased blood
sugar.
Amlodipine ANTIHYPERTENSIVE, Dysphagia, nausea, Decreased salt and
ANTIANGINA, Ca cramps. Edema. calories may be
Channel Blocker recommended. Avoid
natural licorice.
Hydralazine ANTIHYPERTENSIVE, Anorexia, decrease Interferes with pyridoxine
CHF treatment, vasodilator or increase in possible pyridoxine
weight, increased deficiency. Caution with
thirst. Dry mouth, severe renal function.
unpleasant taste,
N/V, GI distress,
diarrhea,
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constipation.
Edema.
Doxazosin ANTIHYPERTENSIVE, Slightly increased Decreased Na and
Alpha1 Adrenergic Blocker weight. Dry mouth, calories may be
dyspepsia, nausea, recommended. Avoid
abd pain, diarrhea, natural licorice.
constipation.
Edema.
Omeprazole ANTIULCER, Nause, abd pain, May decrease absorption
ANTIGERD, Proton Pump diarrhea. of Fe, vitamin B12, and
Inhibitor Ca.
Metoclopramide ANTIEMETIC, Dry mouth, Caution with diabetes
ANTIGERD increased gastric may alter insulin
emptying, nausea, requirements. Caution
diarrhea, with hypertension or
constipation. decreased renal function.
Transient edema.
Epoetin alfa RECOMBINANT Increased blood May need Fe, Vit B12, or
HUMAN pressure. N/V, folate supplementation.
ERYTHROPOIETIN, diarrhea. Monitor renal function.
ANTIANEMIC Monitor Fe, vitamin B12,
and folate levels.
Nephrocaps Vitamin B Drowsiness, Take with food if stomach
complex/vitamin headache, mild irritation occurs. Do not
C/biotin/folic acid; dietary diarrhea, nausea. take other large doses of
supplement for patients on these vitamins
dialysis concurrently.

Vitamin C needed for

healing of wound on left
foot.

Nutrition-Focused Physical Findings: (5 points)

Wound on left foot s/p skin cancer excision. Fragile and easily bruised skin on back and arms.
No pressure ulcers. Left ankle appears puffy, per RD and MD notes. No muscle or fat wasting
noted. No edema noted. GI issues are resolved and patient is eating. No issues with swallowing
or self-feeding. Appetite is coming back, per patient report.

Pertinent Social History: (5 points)

HK is white, Lutheran, widowed, and retired. She is a prior smoker (quit 30 years ago) and does
not drink alcohol. She is on Medicare but not Medicaid. HK usually lives independently, but has
been living with her son and daughter-in-law because of hospitalizations and changes in health
status. When I spoke with HK, her son was keeping her company during her dialysis treatment.

Nutrition History, Diet PTA: (5 points)

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HK usually shops and cooks for herself, but PTA (between hospital stays), she had been eating
what her daughter-in-law cooks. When feeding herself, HK typically eats 4-5 oz of meat such as
chicken, steak, or hamburger for dinner along with white bread, white rice, and two vegetables.
She has good knowledge of foods high in potassium that she needs to limitshe mentioned
bananas, oranges, melons, root vegetables, milk, and tomato sauce. She admits that she cheats
sometimes and has tomato sauce on zucchini noodles, but is still careful not to eat a lot of the
sauce.

Summary of Current Intake: (5 points)

HK reports that her appetite is returning. She said that she willed herself to not be nauseous and
told herself that she needed to eat the night prior, and had been fine since. She had corn flakes,
toast with jelly, and peaches for both dinner the night prior and for breakfast that morning. She
planned on ordering a chicken salad sandwich and a salad for lunch. These choices indicate that
she has good knowledge of how to choose meals without high potassium foods.

DIAGNOSIS (5 points)

PES: Increased protein needs related to hemodialysis as evidenced by recent initiation of

hemodialysis treatment and low serum albumin levels.

Decreased sodium, potassium, phosphorus, and calcium needs related to stage IV kidney disease
as evidenced by medical diagnosis and initiation of hemodialysis treatment.

INTERVENTION (15 points)

Food and/or Nutrient Delivery:

HKs diet order should be changed to renal controlled dialysis (high protein, 2 gram sodium, 2
gram potassium) in order to accommodate higher protein needs conferred by dialysis treatment.
Amounts of phosphorus and calcium should also be controlled, as hemodialysis does not
effectively filter out enough excess phosphorus and it is important to keep minerals in balance.

Nutrition Education:
HK has already been provided with a handout on low-sodium and potassium foods by hospital
dietitian, and demonstrates good knowledge of foods high in sodium and potassium that she
needs to avoid. HK should be educated on the importance of limiting phosphorus for bone
health, and should be provided with a list of foods high in phosphorus and low phosphorus
alternatives (see handout attached). HK should also be educated on eating a high protein diet
what foods and how much of them constitute a serving of protein and tips for incorporating more
protein into the diet (see handout attached).

Coordination of Nutrition Care:

Coordination with physician to change diet to renal controlled dialysis. Coordination with
nursing staff to monitor intake of meals, Is and Os, and wound healing. Referral to outpatient
dialysis center. Referral to outpatient dietitian for nutrition monitoring and continued education
on renal dialysis diet.
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MONITORING AND EVALUATION (10 points)

Food/Nutrition Related Outcomes
o Monitor intake to ensure that intake is good, >75% of meals.
o 24-hour recall to ensure that patient is consuming adequate protein and
appropriate levels of electrolytes and minerals
Anthropometric Measurements Outcomes
o Weigh the patient to monitor for signs of fluid retention.
Biochemical Data, Medical Tests, and Procedure Outcomes
o Monitor Na, K, and Cl to assess fluid balance, effectiveness of and compliance
with dialysis treatment.
o Monitor serum phosphorus, if too high this confers risk to bone health.
o Monitor corrected calcium for signs of deficiency.
Nutrition-Focused Physical Findings Outcomes
o Monitor for signs of edema.
o Monitor for signs of muscle or fat wasting.
o Monitor wound healing so that zinc supplementation can be ceased at the
appropriate time.
Nutrition Education Outcomes Knowledge-based
o Patient will be able to identify dairy as the primary source of phosphorus in the
diet and understand that it needs to be limited.
o Patient will be able to recall at least one tip for incorporating more protein into the
diet.

MEAL PLAN
1. Current Nutrition Dx: (5 points)
1600 kcal
71-77 g protein
2 g sodium
2 g potassium
Limit phosphorus to 800-1200 mg/day
Limit calcium to 2000 mg/day
About 1600 mL fluid/day
o May need to alter based on urine outputs

2. Menu Plan (5 points)

Sample meal plan, calculated using MyFitnessPal and USDA Food Reference Database
Meal/Snac Food Kcal Carb Fat Pro Na K P Ca Water
k
Breakfast 3/4 cup Corn 75 18 0 2 150 34 29 1 0
Flakes
2 large eggs, 203 3 15 14 342 168 201 81 0
scrambled
1 slice white 120 22 2 3 150 0 0 135 0
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bread
1/2 cup sliced 60 14 0 0 5 100 28 8 0
peaches
3/4 cup 1% 75 10 2 6 79 255 174 229 165
milk
8 fl oz water 0 0 0 0 0 0 0 0 237
Lunch 2 slices white 240 44 3 6 300 0 0 270 0
bread
1 oz chicken 43 0 1 9 15 111 219 4 0
breast
1 Tbsp light 32 2 3 0 15 1 0 0 0
mayonnaise
1/8 cup 2 0 0 0 10 33 3 5 0
chopped celery
1/2 cup sliced 60 15 0 0 5 55 0 0 0
pears
2 cups mixed 22 0 0 0 0 0 28 31 0
lettuce
2 tsp olive oil 80 0 9 0 0 0 0 0 0
1 tsp red wine 1 0 0 0 0 0 0 0 0
vinegar
8 fl oz water 0 0 0 0 0 0 0 0 237
Snack 1 medium 80 22 0 0 0 170 20 11 0
apple
2 Tbsp peanut 190 8 16 7 140 0 107 16 0
butter
8 fl oz water 0 0 0 0 0 0 0 0 237
Dinner 3 oz rotisserie 120 1 3 22 380 0 209 11 0
chicken breast
1/2 cup cooked 19 4 0 1 1 107 20 28 0
green beans
1/2 cup white 121 27 0 2 0 27 34 3 0
rice
1/2 cup corn 72 16 1 3 1 162 57 2 0
8 fl oz water 0 0 0 0 0 0 0 0 237
TOTAL 161 206 55 75 159 122 1129 835 1113
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Additional meds, pertinent Drug/Nutrient Interaction Information not addressed in note: (5

points) None.

References: (5 points)
Mahan, L. Kathleen, and Raymond, Janice L. Krause's Food and the Nutrition Care
Process. 4th ed. St. Louis, MO: Elsevier, 2016. Print.
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Pronsky, Zaneta M., Dean Elbe, and Keith Ayoob. Food Medication Interactions. 18th ed.
Birchrunville, PA. 2015. Print.
Nutrition Care Manual, Academy of Nutrition and Dietetics
Escott-Stump, S. Nutrition and Diagnosis-Related Care. 8th ed. Philadelphia, PA: Wolters
Kluwer, 2015. Print.