Beruflich Dokumente
Kultur Dokumente
Pt Initials:
HD
Appointment length:
60 min
ASSESSMENT
Client History
Reason for visit:
Nephrologist referral for implementing renal diet. Daughter present.
Personal hx:
70 yo German American M. Quit smoking 5 years ago.
Medical hx:
Dx c ESRD; recently started HD 3 x week. Dx c T2DM 10 years ago. Probably undiagnosed for several
years. Muscles cramps, ankle edema, fatigue, loose-fitting dentures.
Family Med hx:
N/A
Social hx:
Fixed income. Lives alone; one daughter, attentive and local. She takes HD to dialysis appts or he takes
Access Ride medical transport. Mostly homebound.
%ideal/reference weight:
100%
%usual weight:
unknown, 90% of UBW from 1 year ago
Weight change classification
: of concern
DIAGNOSIS
Problem:
Excessive potassium intake (NI-5.10.2.5) related to
Etiology:
difficulty implementing renal diet and decreased kidney function as evidenced by
Signs and Symptoms:
serum potassium of 6.4 mEq/L and reported potassium intake 215% of ESRD diet guidelines.
Problem:
Excessive Fluid Intake (NI-3.2) related to
Etiology:
difficulty implementing renal diet and high intake of high sodium processed foods as evidenced by
Signs and Symptoms:
5.5 L fluid gain between dialysis treatments, low serum sodium (126 mEq/L), ankle edema,
reported fluid intake 184% of ESRD diet guidelines, reported sodium intake 306% of ESRD diet guidelines.
INTERVENTION
Nutrition Prescription
REE/ Kcals:
2433 - 2780 kcal/day (35-40 kcal/kg)
Protein (g/kg):
1.2 g/kg = 83 g/day
Fluids (ml/kg):
3 cups + Urine output (240 mL) = 4 cups = 960 mL/day
Other:
K+ intake of 2 to 3 g/day; Na+ intake of 1.5 - 2 g/d; PO4 intake of 1.2 g/day (1 serving dairy/day; limit
convenience foods, prepared foods, fast foods; limit beans, nuts, bran); TUMS for Ca2+ and phosphate binding with
meals.
Intervention 1: Meals and Snacks - Mineral-modified diet - Decreased potassium diet (ND-1.2.11.5.2):
Explained
risk of cardiac arrest with excessive potassium intake with ESRD and identified tomato products as high in potassium.
Instructed pt and daughter on how to look for potassium chloride on packaged food labels especially for low-sodium
foods and provided Potassium and Kidney Disease Handout. Went through list of high, medium, and low potassium
foods with pt to identify preferences. Brainstormed affordable and convenient meal options with goal of less than or
equal to 1 serving/d of high K+ food, 2 servings/d medium K+ food, and 3 servings/d low K+ food (eg meals: tuna
salad, egg salad, chicken and penne pasta). Daughter agreed to read labels, purchase from this list, and pt agreed to
consume these foods.
Intervention 2: Nutrition Education-Content-Recommended modifications (E-1.5):
Explained relationship between
fluid intake and intake of high sodium food (canned soup and frozen dinners) and risks of excessive fluid gains.
Explained fluid intake includes drinks, soups, ice cream, & anything that melts at room temperature. Brainstormed
affordable convenient low sodium processed food options for daughter to purchase that contain <600 mg/serving and
provided Sodium: Shake the Salt Habithandout. Explored options for managing thirst such as sucking on ice chips
and sugar free hard candy, and spreading fluid intake out throughout the day. Pt agreed to try Healthy Choice Low
Sodium frozen meals (~560 mg Na+/serving) for dinner until next appointment and limit fluid intake to 960 mL (split
into 1 cup 4x day including drinks, soups, ice cream, etc).
MONITORING /EVALUATION
Professional goal #1:
To address hyperkalemia, at 2 day follow up visit, pt demonstrate intake of 2-3 grams
potassium/day as reflected by 24 hour recall.
BASTYRCENTERFORNATURALHEALTH
NutritionTeamCare
NutritionConsultation
Name:
HD
DateofBirth:4/19/1945
Clinician:
LizSullivan
Date:
5/15/15
NutritionalRecommendations:
Thankyouforcomingintoday,HD.Herearethegoalswediscussedfortodaysvisit
on5/15/15:
Startingtoday,yourdaughterwill:
Willreadfoodlabelstocheckforpotassiumchloridecontent(especiallylow
sodiumfoods)
UsethePotassiumandKidneyDiseasehandouttopurchasemostlylow
andmediumpotassiumfoods
Willpurchaselowsodiumpackagedfoods,includingHealthyChoicefrozen
mealsfordinner
Startingtoday,Iwill:
Eatlessthanorequalto1high,2medium,and3lowpotassiumfoodsper
dayasnotedbythePotassiumandKidneyDiseasehandout
Limitfluidconsumptionto~4cups/32fluidouncesperday(includingfoods
thatareliquidatroomtemperature)
Useicechipsandsugarfreecandytomanagethirst
Spreadsmalleramountsoffluidsthroughouttheday(~1cup4x/day)
Consumefrozenmealswithlessthan600mg/sodiumatdinner
NextAppointment:
ClinicPhone:(206)8344100
Time
Food
Amount
9:00 am
Breakfast
2 ea
1 tbsp
cup
cup
1 ea
6 fl oz
1 tbsp
10:00 AM
Snack
cup
1 each
3 tbsp
1:00 PM
Lunch
2 slices
3 ounces
1 tbsp
cup
2 each
cup
8 fl oz
4 PM
Snack
Apple sauce
Decaf iced tea
cup
6 fl oz
8:00 PM
Dinner
Salisbury steak
Gravy
White Rice with...
Unsalted butter
Green beans, cooked from frozen, drained
Dinner roll, 2.5 inches
Water
TUMS supplement
3 ounces
cup
1 cup
2 tbsp
1.5 cup
1 each
6 fl oz
10:00 PM
Snack
Cherry Pie
1 slice
Patients underdoing hemodialysis often have widespread systemic inflammation, putting them at particular risk for
cardiovascular disease. L-carnitine is important for the beta-oxidation and intermitochondrial transfer of long chain
fatty acids, but is often low in patients with ESRD because of low production levels in kidney and liver and losses
during dialysis. L-carnitine is thought to suppress inflammatory cytokines that may contribute to the inflammatory
process. Levels of C-reactive protein can specifically be used to measure systemic inflammation and is reflective of
other inflammatory compounds being released. A 2006 study by Duranay, Akay, Yilmaz, et al showed that IV
L-carnitine supplementation at a dose of 20 mg/kg led to a significant reduction in CRP levels, indication a reduction in
inflammation. Albumin and transferrin are negative acute phase proteins that are suppressed by inflammation.
Researchers saw that administration of L-carnitine also led to increases in albumin and transferrin, an ideal outcome
for ESRD patients. ESRD patients are at particular risk for hypoalbuminemia which can alter tissue recovery and
repair; transferrin transports iron within the body and decreases can contribute to anemia of chronic disease. Its
important to note that this study was conducted with IV L-carnitine and that other studies on both oral and IV
L-carnitine have been mixed in regards to patients with ESRD. More research needs to be done to assess effectiveness
of this alternative treatment.
Duranay M, Akay H, Yilmaz FM, Senes M, Tekeli N, Yucel D. Effects of L-carnitine infusions on inflammatory and
nutritional markers in hemodialysis patients.
Neprhol Dial Transplant.
2006; 21: 3211-3214.