4/24/15,

8:00am


Assessment:
Pt admitted to hospital with chest pain after walking up stairs. She lives with her
daughter and their family, and her daughter is uneducated about a renal diet but
prepares all meals. Observed edema of the lower extremities and pt sounds
congested. Pt says she follows a renal diet at home. She states she sees a dietitian
once a month at her HD unit and is told to eat more protein. Pt reports that she does
not eat bananas, oranges, tomatoes or potatoes because they contain too much
potassium. Based on nurses notes, pt is consuming 60% of most meals.

69 yo AA female; Dx: Acute MI; PMH: ESRD, Type II DM (18 yrs.), HTN (44 yrs.)
Ht. 5 8; Wt. 163#; SBW 156#; %SBW 104.5%; IBW 140#; %IBW 111.4%; BMI 23.7

(normal) (based on SBW)
Labs (Ranges for CKD): K+ 5.8 mg/L (WNL), BUN 108 mg/dL (high), Cr 10.8 mg/dL

(WNL), Hgb 11.0 g/dL (WNL), Hct 36% (WNL), Phos 6.5 mg/dL (high),

Albumin 2.5 g/dl (low), Mg 3.2 mg/dL (high), Chol 272 mg/dl (high), RBG

186 mg/dL (WNL)
Meds: Bumex, Phos-lo, Epogen, Nephrovite, glipizide, zocor
I/O: 60% PO intake (47% of EER)
EER: 2130 -2480 kcal (based on 30-35 kcal/kg, SBW); EPR: 85 g
Current diet: Renal diet 60 gm protein, 2 gm K+, 2 gm Na+, 1200 ml fluid

Restriction Diabetic diet- 1800 ADA


Diagnosis:
Malnutrition related to physiological causes increasing nutrient needs due to CKD
on HD as evidenced by fluid accumulation localized in lower extremities and report
of estimated energy intake less than 50-75% of EER.

Altered nutrient-related laboratory values related to kidney dysfunction as evidence
by high BUN (>80 mg/dL), magnesium (>3.0 mg/dL) and phosphorous (>5.5
mg/dL) levels.

Excessive phosphorous intake related to lack of knowledge about management of
diagnosed renal insufficiency requiring phosphorous restriction as evidence by
hyperphosphatemia (>5.5 mg/dL).


Intervention:
1. Recommend increased energy needs to 2300 kcal/day and protein needs to 85
g/day (at least 75% HBV) within the NRD diet and compliant with diabetes (ADA).
Recommend percentage of total kcal intake be 55% carbs (316 g) and 30% fat (77
g), with saturated fat only 7% of total kcal. Phosphorus limited to 1 g/day.

Potassium and sodium limited to 2 g/day. Fluid 1200 mL/day. Given handout on
HBV protein sources.
2. Educated pt and daughter on renal diet. Provided handout.
3. Consulted pt about food preferences and informed daughter of food preferences.
4. Educated patient and daughter on high-phosphorus foods to limit. Provided
handout.
5. Recommend pt and daughter attend a renal diet cooking class.
6. Recommend light physical activity, such as walking, for at least 20 minutes a day,
four times a week.


Monitoring/Evaluation:
1. Pt weight and labs status will be measured post dialysis. Follow-up visits will
continue every 2 weeks until all lab values are WNL.
2. Pt will keep a food journal. Caloric intake will increase to 2300 kcal/day and
protein intake to 85 g/day (at least 75% HBV). Phosphorus intake will be limited to
1 g/day.
3. Pt will adhere to renal diet with help from adherence by her daughter.
4. Pt will add favorite foods into daily meals as measured by food journal.
5. Pt will limit intake of high phosphorus foods as measured by food journal.
6. Pt will attend a renal food cooking class with her daughter.
7. Patient will keep a physical activity log and participate in physical activity for at
least 20 minutes a day, four times a week.




Signature:

Nicolette Leffler