Download File - Kimberly A. Labrecque

Sage NCP Form
Patient: Ms. C
Student Name: Kimberly LaBrecque
Case No. 19
Referred for: Nutrition Counseling and Education on Dialysis Diet
NUTRITION ASSESSMENT
Food and Nutrition Related History: Patient is a married, 49 year old female status post kidney transplant x 2 due to history of
membranoproliferative glomerulonephritis diagnosed 15 years ago. Patient has previously been treated with hemodialysis and peritoneal dialysis
and is currently admitted for acute kidney rejection and chronic allograft nephropathy as well as insertion of peritoneal dialysis catheter to initiate
dialysis. Patient would like to continue CCPD so she can work during the day. Patient reports dyspnea, nausea and reduced appetite due to bad
taste in food. Patient also has a history of hypertension, anemia related to chronic kidney disease and dyslipidemia.
Anthropometric Measurements
Age: 49
Gender
Ht: 157.4 cm
Wt: 77.1 kg
Female
Wt Hx: 74 kg
Biomedical Data, Medical Tests & Procedures
Labs/Date Albumin
Glucose GFR
BUN
Creat
Na+
K+
1/21/13
3.4
80
6
124
6.8
130
3.8
mg/dL
mg/dL
mL/min/
mg/dL
mg/dL
mEq/L
mEq/L
1.73 m2
Medical Diagnosis/Relevant Conditions:
Status post kidney transplant X2 experiencing acute rejection with chronic allograft nephropathy
BMI: 31.1
Usual BMI: 29.9
Hgb
6.6 g/dL
Hct
19.0 %
MCV
65.3 µm3
Phosphate
11.9
mg/dL
Pertinent Medications/Supplements/Herbs:
Procardia, carvedilol, Catapres, CellCept, fish oil, Lasix, prednisone, Gengraf, Prinivil, sodium bicarbonate, calcitriol, renal caps and Renvela
Skin status: X Intact □ Pressure Ulcer/Non-healing wound; Comments:
Patient/Client/Family Medical/Health/CAM History:
Patient: membranoproliferative glomerulonephritis; allograft transplant X2; hypertension; dyslipidemia; anemia of chronic kidney disease
Family History: Mother – cervical cancer; Father – lung cancer
Estimated Nutritional Needs Based on Comparative Standards:
Calories
Protein
Pre-dialysis: 1500 to 1600 kcal/day for weight
Pre-dialysis: 41 to 45 g/day minimum based
maintenance (based on Mifflin St. Jeor formula on the patient’s adjusted body weight and
and stress factor of 1.1 to 1.2)
current body weight (allowing for net fluid
gain of 2 kg)
Once dialysis commences: 1800 to 1900
kcal/day based on KDOQI guidelines of 35
Once dialysis commences: 82 g to 89 g/day
kcal/kg, allowing for 60 to 70 percent glucose
per KDOQI guidelines of 1.2 to 1. 3g/day for
absorption from dialysate
patients on peritoneal dialysis
Current Diet Order
Feeding Ability
Oral Problems
x Independent
□ Chewing Problem
1500 kcal, 75 g protein,
□ Limited Assistance
□ Swallowing Problem
3000 mg Na, 3500 mg K,
□ Extensive/Total Assistance
□ Mouth Pain
1000 mg P, 2000 cc fluid
x None of the Above
□ No Nutritional Diagnosis at this time
Fluid
Pre-dialysis: 2000 mL to 2400 mL/day
(30 to 35 mL/kg adjusted body weight)
Once dialysis commences: minimum of 2000
mL/day (30 mL/kg adjusted body weight)
Intake
□ Good (> 75%)
X Fair (approx. 50%)
□ Poor (<50%)
□ Minimal – (<25%)
x Proceed to Nutrition Diagnosis Below
NUTRITION DIAGNOSIS
P (problem) Altered nutrition-related
laboratory values (NC-2.2) related to:
P (problem) Impaired nutrient utilization
(NC 2.1) related to:
E (Etiology)renal failure from
membranoproliferative glomerulonephritis
and acute kidney transplant rejection as
evidenced by:
E (Etiology) kidney dysfunction and inability
to filter and eliminate metabolic wastes (urea,
ammonia, nitrogen) as evidenced by:
S (Signs & Symptoms)
GFR of 6 mL/min/m2, serum phosphate of 11.9
mg/dL and serum albumin of 3.4 g/dL
S (Signs & Symptoms)
GFR of 6 mL/min/m2, BUN of 124 mg/dL and
serum creatinine of 6.8 mg/dL
INTERVENTION
Recommended Nutrition Prescription:
Pre-dialysis: Initiate modified diet to 1500 to 1600 kcal/day for weight maintenance; reduce protein intake of 41 to 45 g/day of high quality protein
sources (lean meats, egg whites); reduce phosphorus intake to 800 to 1000 mg/day; limit potassium to 2 to 3 g/day; and sodium to 2 to 3 g/day as
well as fluid intake to no more to 2000 to 2400 mL/day to reduce edema and fluid weight gain. Diet should involve the following macronutrient
ranges per day: Carbohydrates 45 to 65 percent; protein 10 percent; fat: 25 to 35 percent; and saturated fat less than 7 percent of total kilocalories
per day.
Food or Nutrient Delivery:
Nutrition education:
Meals and Snacks (ND-1)
Educate patient on appropriate protein and energy intake before and
Current admitting orders:
during dialysis as well as the phosphorus, sodium and potassium
1500 kcal, 75 g protein, 3000 mg sodium, 3500 mg potassium,
content of foods and beverages. Provide handouts related to the
1000 mg phosphorus, 2000 mL fluid
protein and mineral content of foods high in phosphorus, potassium
and sodium as well as proposed meal plans for patients with end stage
renal disease and dialysis. Once dialysis begins, educate patient on
increased protein and energy needs as well as allowance for additional
energy from dialysate.
Nutrition Counseling:
Coordination of Care (refer to):
Encourage patient to modify diet to reduce processed, fast foods and
limit colas or beverages high in phosphorus. Recommend switching
Nephrologist, primary care physician, renal dietitian
from fatty meats to lean meats and poultry. Based on the patient’s
reported decline in appetite, determine what foods she prefers and
how to prepare high quality protein and other foods to make them
more palatable.
Goal(s):
Short-term (pre-dialysis): Modify patient’s energy intake to 1500 to 1600 kcal/day while limiting protein to 41 to 45 g/day of high quality protein.
Reduce patient’s phosphorus to 800 to 1000 mg/day; limit potassium to 2 to 3 g/day; and sodium to 2 to 3 g/day as well as fluid to 2000 to 2400 mL
per day to gradually improve patient’s GFR, BUN and creatinine levels.
Long-term: Initiate diet plan for peritoneal dialysis patients according to KDOQI guidelines. Increase energy intake to 1800 to 1900 kcal per day
with 82 to 89 grams of protein daily from high quality protein sources to replace protein losses from dialysis as well as gradually increase patient’s
albumin levels to at least 4 g/mL. Continue with reduced phosphorus diet; reduce sodium to 2000 mg/day (for renal and hypertension
management); limit potassium to 2 to 3 g/day; and maintain at least 2000 mL fluid intake/day to improve GFR, BUN and creatinine levels over time
in adjunct to dialysis and medication management.
MONITORING & EVALUATION
Indicators:
Monitor patient’s laboratory values (including GFR, phosphate and
albumin as well as BUN, calcium, sodium and potassium) to assess renal
function on a daily basis. Once a day, evaluate the patient’s weight,
intake and output as well as the patient’s appetite and acceptance of
diet.
Once the patient is discharged and on dialysis, monitor her laboratory
values and weight on a monthly basis. Evaluate diet through 24-hour
food recalls and/or records to determine phosphorus, potassium, and
sodium intake as well as acceptance and compliance of diet and lifestyle
changes. Monitor protein to ensure patient’s intake is adequate (from
high quality sources) to improve albumin levels over time and avoid
excess protein depletion from dialysis.
Criteria:
In hospital: Initiate modified energy diet to 1500 to 1600 kcal per day
for weight maintenance. Reduce protein intake to 41 to 44 g per day as
well as phosphorus to 800 to 1000 mg, potassium to 2 to 3 g, and
sodium up to 2 g per day to gradually improve GFR, phosphorus and
sodium levels.
Outpatient: Increase energy intake to 1800 to 1900 kcal and protein to
82 to 89 g per day while on dialysis to avoid excess protein depletion
and improve serum albumin levels. Maintain reduced phosphorus
intake of 800 to 1000 mg along with potassium of 2 to 3 g and sodium
up to 2 g per day to gradually improve renal function. Evaluate the
patient’s GFR, BUN, creatinine, phosphate, potassium and sodium
levels. Meet with the patient on a monthly basis to evaluate labs,
overall renal function, diet and energy intake.