Nutrition First Office Call

Pt Initials: HD

Appointment length: 60 minutes

ASSESSMENT
Client History
Reason for visit: Nephrologist referral for implementation of renal diet.
Personal hx: 70 y.o. single German American male, former smoker (quit 5 yrs ago).
Medical hx: Diagnosed c ESRD. Recently started on HD 3x/wk. Diagnosed c Type II DM 10 yrs
ago. Muscle cramps, swollen ankles, fatigue, and loose dentures.
Family Med hx: Not assessed.
Social hx: Pt lives alone, mostly homebound, but a supportive daughter lives close by to assist
with some meals and transportation. Pt also relies on Access ride for transportation. Daughter is
present at appointment. Fixed income.
Food and Nutrition-Related History
Food and Beverage Intake and/or Nutrition Intake Analysis Results:
B: Often skips as he sleeps late and doesnt have much of an appetite lately. Drinks
1 cup coffee with 2 Tbs half and half when he wakes up. S: (11 am) 8 ounces orange
juice and 2 slices toast with butter L (1:00 pm): 2 cups canned tomato soup (tomato
is his favorite) 12 saltine crackers with 1 ounce sliced cheddar cheese and 8 ounces
2% milk. D (8 pm): Hungry man TV dinner (Salisbury steak is his favorite) and 12 oz
iced tea.S: (10 pm) 1cup chocolate ice cream
Pt consumes 2 small meals, c 1 morning and 1 evening snack. Pt does not eat
breakfast. Pt consumes inadequate Kcals (71-81% of renal diet), inadequate protein
(53-62% of renal diet), 51% of calories from carbohydrates (WNL for AMDR), 36% from
fat (slightly above AMDR), 19% of calories from saturated fat (high compared to 5-6%
recommendation), excess water via food and drink (162% of renal diet), excess
sodium (230% of renal diet), excess potassium (142-212% of renal diet). Intake of
phosphorous is WNL at 0.87g (0.8-1.2 recommended for renal diet). Low intake of
omega 3 fatty acids (48% of AI). Inadequate fiber intake (70% of AI). No ETOH intake.
Food and Nutrition History: Pt often eats canned or frozen meals.
Knowledge/Beliefs/Attitudes/Behaviors: Pt is having trouble with diet changes specifically
trouble remembering what he learned in renal diet class. Pt described by daughter as set in
ways. Pt dislikes taste of Tums and forgets to take them c meals. Pt has not much of an
appetite lately.
Food Access and Preparation: Pt is on a fixed income and daughter buys pts groceries at the
Grocery Outlet or Safeway. Pt often feels fatigued and doesnt have energy to cook so relies on
easy to heat up foods or daughter will make and bring food.
Food allergies/Intolerances: NKFA.
Physical Activity: No reported exercise.
Medications and Dietary Supplements: Atenolol, Erythropoietin, Miralax, Sertraline,
Ferrlecit, Insulin (lantus basal insulin), Nephrocaps, Zemplar, Tums (not taken as directed).
Anthropometric Measurements
Height (in/cm): 70/117.8 cm
Weight (lb/kg): 153 lbs/ 69.5 kg (Dry Weight)
BMI: 22.0 (normal)
Weight hx: 1 year ago: 170 lbs. 3 months ago: 159 lbs. Weight before last dialysis session: 165
lbs. Weight after last dialysis session: 160 lbs. Pt gained 12 lbs water weight between last
dialysis sessions (7.8% body weight). Pt lost 10% dry weight in past year.
Other measurements: None.
Ideal/reference weight: 166 lbs, range: 149-183 lbs
Usual weight: 170 lbs one year ago

%ideal/reference weight: 103%

%usual weight: 90%

% Wt change: 10% weight loss in past yr

Desired weight: Weight maintenance.

Weight change classification: Of concern.

Biochemical Data, Medical Tests and Procedures

Pertinent labs/tests/procedures: BUN 20 mg/dL (low), Albumin 3.0 gm/dL (low), K+ 6.4
mEq/L (high), Na+ 126 mEq/L (low), PO4 7.2 mg/dL (high), Serum Calcium 8.1 mg/dL (low), HCT
36% (low), HGB 12.2 g/dL (low), Ferritin 21 ng/L (low), TIBC 455 mcg/dL (high), Transferrin 366
mg/dL (high), Triglycerides 244 mg/dL (high), Urine output: 240 ml.
The following test are WNL: FBS, HbA1c, Total Cholesterol.
Nutrition Focused Physical Exam Findings
GI Function: Chronic constipation, BM every 2-3 days
Sleep hx: Poor sleep at night due to sleep during dialysis. Pt is kept awake at night by muscle
cramps.
Energy: Feels fatigued.
Stress: Not assessed.
Blood pressure: 143/92 mmHg (High)
Overall clinical observation: Pt dentures are loose fitting. Pt is slow in movements and
reaction time and appears sleepy. Pt falls asleep several times during appointment, but daughter
is attentive. Signs of edema in ankles.

DIAGNOSIS
Problem: Excessive mineral intake (Potassium, NI-5.10.2.5)
Etiology: Difficulty remembering and implementing renal diet for ESRD.
Signs and Symptoms: Intake of 142-212% of recommended potassium for ESRD, serum
potassium of 6.4 mEq/L (high), muscle cramping and fatigue.
Problem: Excessive fluid intake (NI-3.2)
Etiology: Inability to remember therapeutic diet for ESRD.
Signs and Symptoms: Intake of 162% of recommended fluid for ESRD, intake of 230% of
recommended sodium for ESRD, serum sodium level of 126 mEq/L (low), high blood pressure
(143/92 mmHg), and signs of edema in ankles.

INTERVENTION
Nutrition Prescription
REE/ Kcals: 35-40 kcals/kg= 2433-2780 kcals/d
Protein (g/kg): 1.2 g/kg= 83 g/d
Fluids (ml/kg): 3 cups (710 ml) + urine output (240 ml)= 950 ml/d
Other: Renal diet: 2g/d of sodium, 2-3 g/d of potassium, 0.8-1.2 g/d of phosphorous. Limit intake
to 1 serving/d of dairy, limit beans, nuts, bran, and convenience, processed, fast foods. Take
phosphorous binders with all meals and snacks.
Intervention 1: Nutrition Education-Content-Priority Modification (E-1.2): Discussed the
importance of keeping serum potassium in recommend range for ESRD of 3.5 to 5.5
mEq/L to prevent cardiovascular damage caused by high levels. Discussed handout on
potassium content of foods and identified agreeable options for pt in each category. Gave
daughter a copy to reference for grocery shopping. Recommended that pt eat only 1 serving of
high potassium food, 2-servings medium potassium food, and 2-3 servings low potassium foods
per day. Recommended that pt and daughter write on a refrigerator calendar a daily meal plan
for pt to reference. Taught pt how to keep a food log and it was decided that pt will record intake
on calendar.

Intervention 2: Nutrition Counseling-Strategies-Problem Solving (C-2.4): Discussed ideal

intake of total fluid (950 ml or 4 cups) to mange fluid and electrolyte balance in ESRD
and brainstormed ways to limit intake considering beverages as well as soups and
watery fruits. Suggested that pt mark a glass and bowl at 1 cup line and mark on
calendar each time a cup is consumed to keep track of intake, including watery foods
and beverages, and not exceeding 4 cups per day. Discussed sodiums role in fluid
retention and recommended that pt limit sodium intake by minimizing intake of high-sodium
processed foods such as premade meals, saltines, and cheese and eliminating addition of
salt to meals. Taught pt and daughter how to read food labels, emphasizing sodium content and
serving size. Discussed choosing soups and packaged foods labeled low sodium and
appropriate fruits and vegetables which are naturally low in sodium. Daughter and pt
agreed to limit sodium from packaged food to 2000 mg in daily meal plans.

MONITORING /EVALUATION
Professional goal#1: To optimize cardiovascular health in ESRD, pt will intake no more
than 2-3 g of potassium/d for 1 out of 2 days before next meeting.
Professional goal#2: To maintain optimal fluid and electrolyte balance in ESRD, pt will
intake no more than 950 ml of fluid/d and no more than 2g sodium/d for 1 out of 2 days before
next meeting.
Follow up: COC c dentist regarding dentures, take TUMs c meals, decrease phosphorous intake,
increase protein intake, increase kcal intake, increase intake of calcium and vitamin D for bone
support, address balance of fat intake including decreasing saturated fat and increasing omega 3
intake, increase fiber intake, address blood sugar control.
Handouts provided: Potassium and Renal Disease Handout
Clinician signature: __________________________