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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.