Date 11/6/19

Time 5:45pm

Patient Name: Enez Joaquin

Referring Physician: L. Nila

Age 24 Gender: F Height: 5’ (1.524m) Weight: 170 (77.3kg)

ASSESSMENT

Demographic: Married, Native American, Secretary, high school education.

Social considerations: lives on the reservation, with limited access to (reservation) healthcare.

Weight History: gained 4kg in past 2-weeks

Weight Goal: maintain UBW; gain <4%BW between dialysis visits

Usual (dry) Weight/%UBW: 73.3kg (105%)

Ideal Weight/%IBW: 45kg (170%)

BMI: 33.3, obese

Activity level: Ambulatory

Food Allergies: NKFA

Nutritional status: Nutrition status declining due to anorexia, N&V, leading to limited intake.
Edema RT to poor protein status.

Medications:

● Glucophage (metformin)
● Capoten/captopril
● Sodium bicarbonate
● EPO
● Renal caps
● Renvela
● Hectorol

Past Medical History: Diagnosed with T2DM 11 years ago (poorly controlled), Diagnosed with
Stage 3 CKD 2 years ago
Relevant Lab Values

● Sodium (low)
● Potassium (high)
● Chloride (low)
● CO2 (high)
● Bicarbonate (low)
● BUN (high)
● Serum Cr (high)
● BUN/Cr ratio (low)
● GFR (low)
● Glucose (high)
● Phosphate (high)
● Calcium (low)
● Osmolality (high)
● Protein (low)
● Albumin (low)
● Cholesterol (high)
● VLDL (high)
● TG (high)
● HbA1C (high)
● RBC (low)
● Hb (low)
● Hct (low)
● pH (high)
● protein (high)
● glucose (high)
● ketones (high)
● pCO2 (low)
● HCO3- (low)

Nutrient Requirements

● Energy: 35 kcal/kg/d: increased needs for dialysis

○ 35 x (73.3- pre fluid loaded wt)= 2,565 kcal
● Protein: 1.2 g/kg/d: increased needs for dialysis
○ 1.2 x current wt (77.3)= 93g
● Fluid: 1,000 mL + output

Nutrient Intake: PO, patient complains of anorexia, N&V

Dietary Intake:

Breakfast: cold cereal, bread or fried potatoes, fried eggs (occasionally), coffee

Lunch: Bologna sandwich, potato chips, coke

Dinner: Chili con carne, indian fry bread, iced tea

Snacks: crackers and peanut butter

(PTA) diet order: Low simple sugar, 0.8 g pro/kg 2-3g Na

Current Diet Order: 35 kcal/kg, 1.2 g/kg, 2g K+, 1g phosphorus, 2 g Na+, 1000mL fluid + urine
output/day

NUTRITION DIAGNOSIS

Altered Nutrition Related Lab values (NC-2.2) RT decreased kidney fx and stage 5 diagnosis of
CKD AEB elevated serum creatinine (12.0mg/dL), elevated potassium (5.8mEq/L), elevated
phosphorus (6.4mg/dl) decreased GFR (4ml/min/1.73 cm2), low sodium (130Eq/L), and low
albumin (3.3 g/dL).

NUTRITION INTERVENTION

Goals

● Meals and snacks

○ Meet energy needs of 35 kcal/kg/d
○ Meet protein needs of 1.2 g/kg/d
■ ensure 50% of protein comes from high BV sources
○ Limit fluid to 1,000mL + output per day
○ Limit food sources of sodium, potassium, phosphorus
■ Phosphorus: Whole grains, legumes, processed foods, sodas
■ Potassium: avocado, cantaloupe, potatoes, nuts, salt substitutes
■ Sodium: processed foods, salts
● Education
○ Importance of weight management between dialysis treatments
○ Food sources of potassium, phosphorus, sodium
○ Timing of Renal caps after dialysis
○ Strategies for reducing fluid intake and foods that count as fluids
■ Ice creams and ice pops, Jell-O, soups, high water content fruits and
vegetables
■ Take small sips of water, chew gum or suck on tart, sugar-free candies
 ○ Nutrition education on high BV proteins
○ Education on not using salt substitutes
● Maintain normal ranges of creatinine, potassium, phosphorous through dietary changes.
○ Limit potassium to 2g/d
○ Limit phosphorus intake to 1g/d

NUTRITION MONITORING/EVALUATION

● Monitor daily
○ Lab values
○ Body weight
○ I/O fluid balance
● Evaluate 24-hr food record within one week

RD Signature

Jenna Laughlin, Imogene Carson, Cameron Vinoskey, Angel Estrella