Karen Brenes-415B- ADIME #1

DATE: April 26, 2015

ASSESSMENT
Pt TW, 69 yo AA female with ESRD admitted with c/o chest pain after climbing stairs. Dx:
Acute MI.
PMH: Type II DM (18 years), HTN (44 years). Pt began HD 5 years ago, currently undergoes
HD 3 days/per wk.
FH: Current diet-Pt reports following a renal diet at home (assuming renal diet= 60g
PRO, 2g K+, 2g Na+, 1200mL fluid per day; Restrictions= ADA Diabetic diet of
1800kcal/day).
Pt visits monthly with dietitian at HD unit who gives her a report card of labs and tells
her to eat more protein.
Pt reports she doesnt eat bananas, oranges, tomatoes or potatoes because theyre high
in K+.
Pt lives with daughter who prepares her meals but hasnt been educated renal diet by a
dietitian.
Nurses notes- Pt consumes 60% of most meals.
AD: Ht= 58; Wt= 163#; SBW post HD= 156#(70.9kg); %SBW post HD= 105%; BMI=
23.8kg/m2 (Normal)
EER: 2482 kcal/day [based on 35 kcal/kg pts UBW, post HD (70.9kg); PA factor= 1.1;
Metabolic Stress= MI, HD].
EPR: 85g protein/day, at least 50% (approx. 43g) HBV [based on 1.2g PRO/kg pts UBW,
post HD (70.9kg)].
Fluids: 1200mL/day (based on 1-1.5L fluid intake if fluid output 1 L)
Labs: (K+)= 5.8 mEq/L(WNL-CKD); (BUN)= 108 mg/dl (High); (Cr)= 10.8 mg/dl (WNL-CKD);
(Hgb)= 11.0 g/dl (WNL-CKD); (Hct)= 36 (WNL-CKD), (Phos)= 6.5 mg/dL (High); (Albumin)=
2.5 mg/dl (Low); (Mg); (Chol)= 272 mg/dl (High); (RBG)= 186 mg/dl (WNL-CKD) (Mg)= 3.2
mg/dl [High-But Mg levels can run normal-mildly elevated in HD pts (1.24-4.04mg/dL),
therefore supplementation not recommended (Nelms, pg. 547)].
Meds: Bumex, Phos-lo, Epogen, Nephrovite, glipizide, Zocor.
Possible food-drug interactions: Grapefruit & Zocor (major), Nephrovite (Ca+ rich foods,
supplements).
PA: Edema of lower extremities, sounds congested.
DIAGNOSIS
1. Inadequate energy intake related to r/t recent poor appetite secondary to CKD and acute
MI and AEB by consumption of only 60% of meals.
2. Altered nutrition related lab values r/t Stage 5 CKD and inappropriate intake of
phosphorus and dietary lipids as AEB serum phosphorus of 6.5mg/dL and serum
cholesterol of 272mg/dL.
3. Food/nutrition related knowledge deficit r/t lack of education on contents and
preparation of renal diet AEB by pt food/nutrition history and self-report.
NUTRITION INTERVENTION
Nutrition Rx: 2482 kcal/day; 85g PRO/day with 43g (approx. 50%) from high-biological
value sources; total fat intake= 621-869 kcals (25-35% total kcals), 174kcals/day saturated
fat (7% total kcal), phosphorus 800-1000mg/day; cholesterol <200mg/day; 2g (2000mg)
sodium/day, calcium<2000, mg/day including binder load; 1200mL/day (based on 1-1.5L
fluid intake if fluid output 1 L)*Recommend adjustment based on changes in output
(increase to 2L/day if output >1L/day).
1. Work with pt to increase her meal consumption to a minimum of 75% of daily meals
prior to discharge.
2. Provide nutritional education on the importance of limiting the following nutrients to pts
health and disease progress: phosphorus intake to 800-100mg/day, cholesterol to
<200mg/day, total fat intake to 25-35% total kcal and sat. fat intake to 7% total kcal.

Karen Brenes-415B- ADIME #1

3. Provide pt and her daughter with booklet on The National Renal Diet along with
recommendations on high phosphorus foods and additives to avoid as well as good
sources of HBV protein that are low in phosphorus and sodium.
MONITORING & EVALUATION
1. Check in on pt daily regarding state of her appetite. Check daily with nursing staff to
further monitor pts intake. Adjust pre-discharge intake goals if necessary.
2. Have pt state her understanding regarding the importance of limiting phosphorus,
cholesterol and sat. fat intakes to recommended levels before discharge.
3. Recommend pt continue to work with dietitian at her HD unit to monitor her diet
compliance and nutrition related lab values both before and after her dialysis
treatments.
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