Nutrition First Office Call

Pt Initials: HD

Appointment length: 60 minutes

ASSESSMENT
Client History
Reason for visit: Pt with ESRD referred by Dr. for renal diet
Personal hx: 70 yo single German American M, former smoker (quit 5 yrs ago)
Medical hx: ESRD, hemodialysis 3 x/wk, Type II DM dx 10 y ago (possibly several yrs prior), pt
reports muscle cramps
Family Med hx: unknown
Social hx: lives alone, homebound, fixed income, receives support from adult daughter
Food and Nutrition-Related History
Food and Beverage Intake and/or Nutrition Intake Analysis Results: Typical day: B: Often
skips as he sleeps late and doesnt have much of an appetite lately. Drinks 1 cup coffee with 2
Tbs half and half when he wakes up. S: (11 am) 8 ounces orange juice and 2 slices toast with
butter. L (1:00 pm): 2 cups canned tomato soup (tomato is favorite) 12 saltine crackers with 1
ounce sliced cheddar cheese and 8 ounces 2% milk. D (8 pm): Hungry man TV dinner (Salisbury
steak is his favorite) and 12 oz iced tea. S: (10 pm) 1cup chocolate ice cream. Current diet is
high in K+: 4146 mg (180% of recommended for ESRD), Na++: 4653 mg (258 % of recommended
for ESRD), high in saturated fats: 40 g (194% of recommended). Diet contains 1960 kcals (ESRD
35/kg = 2430 kcal, 80% of needs), fluid intake 1516 mL (150% of needs for ESRD, reflected by
fluid wt gain of 12 lbs between hemodialysis visits).
Food and Nutrition History: No ETOH, no drugs, often eats canned or frozen meals
Knowledge/Beliefs/Attitudes/Behaviors: Dislikes tums, described as set in his ways by
daughter, having trouble with diet changes for ESRD, Pt has loose-fitting dentures.
Food Access and Preparation: Daughter shops (Grocery Outlet and Safeway) sometimes
brings prepared food, pt does not have energy to cook but can re-heat pre-made foods.
Food allergies/Intolerances: NKFA
Physical Activity: Sedentary, homebound
Medications and Dietary Supplements: Atenolol, Erythropoeitin, Miralax, Sertraline, Ferrlecit,
Insulin (lantus basal insulin), Nephrocaps, Zemplar.
Anthropometric Measurements
Height (in/cm): 70/178 cm
Weight (lb/kg): 153 lb/69.5 kg (dry wt)
BMI: 22 (normal)
Weight hx: 6 lb wt loss in 3 mo, 17 lb wt loss in 1 yr. (unintentional)
Other measurements: Fluid gain of 12 lbs between HD sessions
Ideal/reference weight: 149 - 183 lb/ 68 83 kg %ideal/reference weight: 100%
Usual weight:
170 lb/77 kg
%usual weight: 90%
% Wt change: 10% () over one year
Weight change classification:
significant
Desired weight: not assessed
Biochemical Data, Medical Tests and Procedures
Pertinent labs/tests/procedures: BUN 20 mg/dL (), FBS 140 mg/dL WNL, HbA1C 7.2%
borderline high, Albumin 3.0 gm/dL (), K+ 6.4 mEq/L (), Na+ 126 mEq/L (), PO4 7.2 mg/dL (),
Serum Calcium 8.1 mg/dL (), HCT 36% () normal for CKD, HGB 12.2 g/dL, Ferritin 21 ng/dL
(), TIBC 455 mcg/dL mod (), Triglycerides 244 mg/dL (), total cholesterol 190 WNL, Urine
output 240 mL ().
Nutrition Focused Physical Exam Findings

GI Function: Chronic Constipation, BM every 2-3 d

Sleep hx: does not sleep well at night, has muscle cramps and sleeps during HD
Energy: low
Stress: not assessed
Blood pressure: 143/92 mmHg (borderline high)
Overall clinical observation: movements and rxn time are slow, appears sleepy, edema in
ankles, dentures

DIAGNOSIS
Problem: Excessive mineral intake potassium (NI-5.10.2.5)
Etiology: homebound, limited access to healthful options, dx of ESRD
Signs and Symptoms: serum K+ of 6.4 mEq/L (ideal 3.5 5.0 mEq/L) and pt reported frequent
consumption high K+ foods, (4146 mg, 180% of recommended for ESRD).
Problem: Excessive fluid intake (NI-5.6.2)
Etiology: lack of knowledge regarding high Na ++ foods such as saltine crackers, resulting in
overconsumption of fluids
Signs and Symptoms: water wt gain of 12 lbs (dry wt 153 lbs, pre-dialysis wt of 165 lbs) and
dx of ESRD, serum Na++ of 126 mEq/L (ideal 135 145 mEq/L), BP of 143/92 mmHg, pt reported
diet of 4653 mg Na++(258% of recommended for ESRD).

INTERVENTION
Nutrition Prescription
REE/ Kcals: 35 kcals x 69.5 kg = 2430 kcal
Protein (g/kg): 69.5 kg x 1.2 = 83 g (50% HBV)
Fluids (ml/kg): 240mL + 710 mL = 950 mL/d
Other: 2-3 g/d K+, limit PO4 (1 serving dairy/d, limit beans, nuts, pre-packaged highly processed
foods), limit Na+ to 1.5-2.0g/d
Intervention 1: Nutrition education survival information (E-1.3) Explained to daughter
and pt how high K+ in ESRD can cause cardiac arrest, emphasized the importance of keeping K +
levels under control. Discussed importance of low K + foods like peaches, cabbage, onions and
carrots to replace current tomato soup, ice cream and highly processed frozen foods.
Brainstormed with daughter for ways to provide pt with low K + meals. Suggested menu options
that could serve for both pt and daughter, allowing daughter to prepare one meal with extra
servings rather than special meals for pt. Shared a recipe for Crunchy Lemon Chicken by Chef
Aaron McCargo Jr. who specializes in recipes for ESRD. Daughter was more than willing to help if
it did not mean doubling up on food preparation. Decided to fix the same meals for 2 days and
brainstorm for other ESRD compliant foods on f/u after daughter reads the nutrition care for the
kidneys handout, pt was fine with this plan. Set goal for pts 48 hr diet recall to reflect reduction
in K+ by f/u in two days with low K+ menus found on Chef McCargos web page.
Intervention 2: Nutrition education for Nutrition relationship to health/disease (E-1.4)
Discussed the role of Na++ in ESRD and how pts swollen ankles are a sign of fluid retention
called edema. Talked about how lower sodium diet is important to prevent edema, blood pressure
control. Explained the need to reduce sodium intake to prevent uncomfortable thirst. Suggested
ice chips if pts mouth feels terribly dry. Brainstormed options with daughter for making basic
meal adjustments for pt by reducing salty foods such as soup and saltine crackers with simple
options like tuna salad and quick cole-slaw that can be made in ahead in larger quantities and
stored for two days in pts refrigerator. Discussed how adding herbs and spices can add taste and
visual interest. Daughter agreed to pay careful attention to sodium content of pts foods. Set goal
to have pts 48 hr diet recall reflect a substantial reduction in Na ++ content by having tuna salad
for lunch instead of higher Na++ options , by f/u in two days.

MONITORING /EVALUATION
Professional goal#1: To decrease K+ intake and reduce serum K+ levels, on f/u in two days pts
dietary intake will reflect elimination of high K+ foods for a total K+ levels below 2000 mg/d .
Professional goal#2: To decrease Na++ intake and reduction of fluid gains to < 4% between HD
treatments, on f/u in two days pts diet will reflect low sodium foods (< 2000 mg/d) and fluid
consumption ~ 950 mL/d or 3 cups plus urine output.
Follow up: Continue education on diet changes, Fe + content of diet or COC for IV iron and Vit D,
PO4 content of diet, blood sugar monitoring for diabetes control, alternative phosphate binders,
referral to dentist for denture re-fitting, COC with OT for evaluation of home environment and
self-care.
Handouts provided: link to Chef Aaron McCargos website for recipe options:
http://www".ultracare-dialysis.com/HealthyLifestyles/EatHealthy/ChefAaronMcCargoJr.aspx ,
Nutrition Care for the Kidneys
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