Carley Bedell

UCONN Health Center

Date: 3/28/19

ADIME #3

A : Assessment:
Age: 45 Gender: F Admit Date: 3/27/19 Date Seen: 3/28/19 Patient Initials: M.G.

Admitting Dx: Patient M.G. is a 45 year old female who was readmitted to UCONN Health Center
on March 27, 2019 for abnormal potassium levels. Patient M.G. reported was getting blood work
done during her Peritoneal Dialysis when her potassium levels were found high. M.G. She denies
any symptoms such as headache, chest pain, shortness of breath and states being in a regular state
of health when this occurred. Upon admission high blood pressure in addition to high potassium
levels (7 mol/L) were identified. Primary medical diagnoses for hospitalization were hyperkalemia
and hypertension.

 Hyperkalemia occurs when potassium levels in the blood are higher than normal, levels above
6.0 mmol/L can be dangerous. High K+ can result from kidney disease impairing K+ excretion,
medications (such as potassium-sparing diuretics, gastrointestinal hemorrhage,
rhabdomyolysis, catabolism, or metabolic acidosis. 1
 Hypertension (HTN) also known as high blood pressure, occurs when blood pressure levels
exceed 120/80mmhg which can cause damage to organs such as cardiac, peripheral, renal, or
retinopathy organ systems when blood pressure is too high.1

Treatments/Therapies: Upon admission, calcium gluconate, insulin and dextrose, Lasix and repeat
K+ levels. Kayexalate with repeat K+ in 4-5 hours was recommended upon Nephrology consult.
EKG was performed showing no signs of peaked t waves or heart blockers. M.G. is receiving
50mL/hr Dextrose 10% IV infusion continuously. Patient is currently receiving Peritoneal Dialysis
with Peritoneal Dialysis solution (DELFEX) 1.5%.

PMHx: M.G. was last admitted to UCONN Heath Center in January 2019 for an infection in the
peritoneal dialysis catheter exit site and hypertension.

 Chronic Kidney Disease (CKD)-Stage 5 also referred to as End-Stage Renal Disease is when
kidney failure occurs resulting in the inability of the kidney to excrete waste products , maintain
fluid and electrolyte balance , and produce certain hormones. This stage requires dialysis,
transplantation or medical management. 1
 Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease characterized by
production of autoantibodies directed against nuclear and cytoplasmic antigens affecting
several organs. 1
 Hypoglycemia occurs when blood sugar is low (below 70 mg/dl) affecting the brain and
nervous system that can cause sweating, shaking, hunger, headaches, and irritability. 1
 Secondary Hyperparathyroidism of renal origin occurs in patients with chronic kidney failure
and arises when the parathyroid glands become enlarged and release an excessive amount of
parathyroid hormone (PTH) resulting in high blood level of PTH. 1
 Bell’s Palsy is when the muscles on one side of the face become weak or paralyzed resulting
in it drooping or becoming stiff.
Carley Bedell
UCONN Health Center
Date: 3/28/19

 Anemia due to CKD occurs when there is significant damage to kidney function causing a
decrease in production of erythropoirtin (EPO) resulting in fewer red blood cells produced by
the bone marrow.

Height: Weight: BMI IBW % IBW UBW: % UBW:

5’ 4” 74kg 28 124 lb 132% 74kg 100%

(162.6 (163lb) (56.2 kg) (163lb)
cm; 64 in)

G.M is classified as overweight due to BMI of 28

Calculations:

Ideal Body Weight: Women- 100lbs for first 5ft. Add 5lbs each inch over 5in.
100lbs + 5in (4 in) = 124 lbs Ideal Body Weight
𝐴𝑐𝑡𝑢𝑎𝑙 𝑤𝑒𝑖𝑔ℎ𝑡
Desirable Body Weight: %DBW = ∗ 100
𝐼𝑑𝑒𝑎𝑙 𝑤𝑒𝑖𝑔ℎ𝑡
163
%DBW = 124 ∗ 100 = 132%

History of Weight Changes:

No significant weight changes were reported by patient. G.M. reported usual body weight around current
body weight, may fluctuate within 5lb.

Nutrition Requirements:
kcal: Mifflin St Jeor X (AF) X (IF) = (10 X 74 kg) + (6.25 X 162.6 cm) – (5 X 45 y/o) - 161 = 1364 kcal

1293 kcal X 1.2 (IF) = 1637 kcal

kcal/kg = 30-35 kcal/kg x 56.2kg = 1686 kcal-1967kcal

*IBW was used for kg

*30-35kcal/kg range used due to Peritoneal Dialysis energy requirements

1700kcal was decided for calorie requirements due to overweight status, energy needs for dialysis
and to increase dietary compliance
 Carley Bedell
UCONN Health Center
Date: 3/28/19

Protein gm/kg = 1.2 – 1.5 gm/kg =1.2-1.5 g/56.2kg= 67-84 g PRO

*1.2-1.5g/kg was used due to Peritoneal Dialysis requirements

Due to severity/progression of chronic kidney disease and high BUN and Creatinine levels, the
lower range of protein- 67g was used

Fluid = 1cc/kcal or 30 cc/kg: 1700 cc or 1686 cc *IBW used

Method 1: 25ml/kg (patients with renal disease)=25ml/kg x 56.2kg=1405 (rounding to nearest

100)=1400cc fluids

**IBW used for body weight

I would use 1400cc fluids considering continuous IV infusion of dextrose and progression of renal
disease

Other Nutrient Requirements for Peritoneal Dialysis

Potassium= 3-4g/day
Phosphorous= 0.8-1.2g/day
Sodium 1.5-4g/day

Diet Order:
Current Order: Renal, Consistent Carb, low K+

 Continuous IV fluid, dextrose 10% infusion 50ml/hr

Assessment of Appropriateness of current diet order:

Considering M.G. is not diabetic, a consistent carb diet restriction may not be necessary. This may
increase dietary compliance. If blood sugar is consistency irregular after liberalization consider
reintroducing consistent carb restriction.

Labs: Source: Nutrition Care Manual

Date Lab Name Patient’s Normal Significance

Result Range

3/28/2019 Glucose 92 mg/dL 70 - 100 WNL

mg/dL
(158mg/dL
upon
admission)

3/28/2019 POCT Glucose 106 mg/dL 70-180 WNL

mg/dL
 Carley Bedell
UCONN Health Center
Date: 3/28/19

3/28/2019 Blood Urea 85 mg/dL 10 - 20 HIGH, M.G.’s high BUN level indicates low
Nitrogen (BUN) mg/dL dietary compliance despite treatments and diet.
(89 on 3/27) Showing her renal condition is not under control.

3/28/2019 Creatinine 15 6-11g/dL HIGH, related to progressive renal condition and

lack of dietary compliance

3/28/2019 Sodium (Na) 136 mmol/L 136 – 145 System flagged LOW- On lower range. Patient has
(was 139 mmol/L kidney failure and is on diuretics
3/27)

3/28/2019 Potassium (K) 5.7 mol/L 3.5 – 5.0 HIGH, reason for hospitalization. Nephrology is
(was 5.2 mol/L addressing cause. K+ level was 7mol.L upon
3/27) admission

3/28/2019 Chloride (Cl) 104 mEq/L 98 – 106 WNL

mEq/L

3/28/2019 Carbon Dioxide 17 23 – 29 LOW, related with progression of renal disease

(CO2) mEq/L (was mEq/L could be sign of Metabolic acidosis due to
15 on 3/27) decreased function and inability to remove acid
from blood. 5

3/28/2019 White Blood Cell 3.8 k/cmm 5 – 10 LOW, may be related to Hx anemia related to renal
(WBC) k/cmm condition

3/28/2019 Red Blood Cell 4.19 4.7 – 6.1 LOW , hx anemia related to renal condition
(RBC) cells/mcL cells/mcL

3/28/2019 Hemoglobin (Hb) 12.5 g/dL 14 - 18 LOW, hx anemia related to renal condition
g/dL

3/28/2019 Hematocrit (Hct) 40.1 % 42 – 52 % LOW, hx anemia related to renal condition

3/28/2019 Calcium 7.7 mmol/L 8.7-10.5 LOW, damage of kidney from Kidney Failure
mmol/L causes abnormalities to hormones (such as PTH,
Parathyroid hormones) resulting in an imbalance of
calcium and phosphorous levels in the blood. 6

Meds: Source: WebMD

Name Purpose Side Effects Nutritional Concerns
AmLODipine Calcium Channel Swelling of the ankles or feet, Take with or without food. Limit
(NORVASC) Blocker- dilates blood difficult or labored breathing, alcohol.
vessels and improves dizziness, fast, irregular,
blood flow (for HTN) pounding, or racing heartbeat
or pulse, feeling warm,
shortness of breath
Calcitrial Vitamin D3, treats Weakness, headache, Can increase serum creatinine, cause
(ROCALTROL) calcium deficiency drowsiness, nausea, vomiting, hypercalcemia or hypercalciuria
and metabolic bone stomach pain, constipation,
 Carley Bedell
UCONN Health Center
Date: 3/28/19

disease in people loss of appetite, dry mouth,

receiving dialysis urinating more than usual,
increased thirst, metallic taste
in mouth
Calcium Acetate Calcium supplement Irregular heartbeats, low Take by mouth with each meal
(PRIOSLO) used to control the blood magnesium, low blood
level of phosphate in phosphates, low blood
the blood of patients pressure, nausea, stomach
on dialysis upset, itching
Carvedilol Beta Blocker (HTN) Dizziness, lightheadedness, Take by mouth and with food
(COREG) drowsiness, diarrhea,
impotence, or tiredness
Doxazosin Alpha Blockers Dizziness, lightheadedness, Take by mouth with or without food,
(CARDURA) (HTN) drowsiness, unusual tiredness, may cause weight gain, can cause
or weight gain may occur. sudden drops in BP
Furosemide Diuretic Dizziness, lightheadedness, Take by mouth with or without food,
(LASIX) headache, or blurred vision can cause dehydration due to serious
loss of body water, may affect blood
sugar, can reduce potassium level in
blood, limit alcohol
Heparin Anti-Coagulant Mild pain/redness/irritation at Can cause stomach bleeding,
(PORCINE) (prevent blood clots the injection medication contains sodium (not
Injection during dialysis) supposed to have on salt-restricted
diet---may be affecting HTN)
Hydroxychloroquine Autoimmune disease Nausea, stomach cramps, loss May cause low-blood sugar, avoid
(PLAQUENIL) (Lupus) of appetite, diarrhea, alcohol,
dizziness, or headache
Mycophenolate To keep body from Constipation, nausea, Patient is on dialysis and has not
(Cell Cept) rejecting/attacking headache, diarrhea, vomiting, received a transplant based on charts
transplanted organs stomach upset, gas, tremor , reviewed.
or trouble sleeping

PrednisONE Arthritis, blood Nausea, vomiting, loss of Take this medication by mouth with
(DELTASONE) disorders, breathing appetite, heartburn, trouble food or milk, may make blood sugar
problems, severe sleeping, increased sweating, rise
allergies, skin or acne
diseases, cancer, eye
problems, and
immune system
disorders
Sevelamer Lower high Headache, diarrhea, stomach Take by mouth with meals
Carbonate Phosphorous in Blood upset, nausea, vomiting,
(RENVELA) cough, gas, or constipation.

Physical Assessment:
Patient was alert and oriented but not cooperative with interview. She appeared overweight, her hair was
thin and skin slightly pale. G.M. had all her original teeth and is able to tolerate regular textured food and
consistency. Patient appeared tired, her eyes were slightly droopy. She used a bed pan for urinating.
Carley Bedell
UCONN Health Center
Date: 3/28/19

Pertinent Social Hx:

G.M. lives with her husband and 3 children. Her and her husband both share cooking responsibilities but
patient reports her husband does the shopping.

Nutrition Hx, Diet PTA:

Patient G.M. has received nutrition education about her condition and consults with the dietitian where she
receives PD. Patient reports eating 3 meals and occasional snacks such as fruit and crackers. Patient does
not like vegetables and has fruit a few times a week. Typically she consumes rice, chicken, eggs, fish,
broccoli. She drinks mostly water with occasional orange juice at breakfast. Patient was not very
cooperative about giving her diet history. She did state that she “won’t give up” Carbonara pasta, pizza or
chicken fingers but claims she only consumes them once a week. (Based on her lab results, this is not
accurate).

Summary of Current Intake:

The patient is on a renal, consistent carb, low K+. Patient had a light breakfast, scrambled eggs with fruit
with orange juice and chicken tenders for lunch with cranberry juice.

D (Diagnosis) PES:
Limited Dietary Adherence related to renal, consistent carb and low potassium diet as evidenced by High
BUN level ranging between 85-89, High creatinine of 15 and patients limited ability to provide a dietary
recall

I (Intervention):
Organized into 4 categories:

Food and/or Nutrient
Delivery
Nutrition Education
Nutrition Counseling
Coordination of
Nutrition Care
Liberalizing the patients diet from renal, consistent-carb, low potassium to
renal, low potassium will help improve G.M.’s dietary adherence.
Developing routine meals and snacks with smaller portions. Patient will be
recommended to take a calcium with vitamin D to improve calcium levels
and Iron with vitamin C supplement to improve iron. Light walking (15-20
minutes) daily will also be encouraged. Consult with Dr. about Heparin
(PORCINE) Injection and assess whether drug may be contributing to
elevated blood pressure.
Patient will be educated about healthy modifications to her favorite meals
and how to incorporate them while still adhering to her diet restrictions
such a using chickpea pasta like Banza and using a light Carbonara sauce
using light cream and low sodium chicken stock. Education on portion sizes
will be given and how snacks between meals can improve satiety and help
decrease portion sizes. Ways to incorporate more F/V was discussed.
Address the causes for the patient not adhering to her diet and help patient
come up with strategies to overcome them. Help motivate patient to follow
her diet, provide support.
Coordinate with nephrology department, doctor (at hospital), nurse (at
hospital) and coordinate with G.M’s outpatient nephrology doctor/dietitian
 Carley Bedell
UCONN Health Center
Date: 3/28/19

M/E Monitoring and Evaluation:

Organized into 5 categories:

Food/Nutrition Related
Outcomes
Anthropometric
Measurement Outcomes
Biochemical Data, Medical
Tests, and Procedure
Nutrition-Focused Physical
Findings Outcomes
Nutrition Education
Outcomes
Pt will consume at least 75% of her meals and supplements by F/U
Pt will adhere to renal diet by F/U
Pt will report smaller portions and healthier diet modifications by F/U
Pt will walk 15-30 minutes 2-3 days/week by F/U and gradually increase to 3-4
days/week over the next 6 months
Monitor PO intake and supplement intake
Pt will have a gradual 5% weight loss over the next 6 months
Monitor weight
Monitor serum calcium, potassium, H/H, BUN, Creatinine, glucose, and
electrolytes
Monitor blood pressure values
Pt appetite will decrease due to higher diet satiation by F/U
Pt demeanor will improve by F/U due to increase in exercise
Pt will be able to state 3 ways to modify dishes to fit her diet and keep satiated
Pt will display knowledge about decreasing portion sizes by incorporating more
snacks.

Meal Plan:
1. For current Dx explain- Foods Allowed, Foods Not Allowed, Diet Instruction Materials if appropriate.
Describe in your own words the rationale for diet restrictions/modifications
Foods Allowed NPO
Foods Not Allowed N/A

Diet Instruction If diarrhea continues evaluate EN composition and assess other contributing factors
Materials if appropriate such as medication.

Meal Menu Kcal CHO PRO FAT (g) K+ Na+ Phospho

(mg) (mg)
(g) (g) rous (mg)
Breakfast Scrambled eggs (2 eggs) 140 0 12 10 0 140 94
1oz sliced cheddar cheese 115 0 7 10 21.5 182 145
1 medium orange 60 15 2 0 0 0 250
1 pieces whole wheat toast 80 15 3 1 0 150 180
1 tsp butter 34 0 0 3 0 100 3
Water--8oz
Snack Sliced Strawberies (1/2 c.) 60 15 0 0 127 1 37
Sliced peaches (1/2 c.) 60 15 0 0 100 10 100
Water-10oz
 Carley Bedell
UCONN Health Center
Date: 3/28/19

Lunch 2 1” sliced Whole wheat veggie 300 34 14 9 0 520 250

pizza 15 3 1 0 152 240 117
½ cup Roasted Cauliflower 10 0 0 3.8 84 12 8
Water – 8 oz 45 1 4 5 0 85 149
25 5 2 0 88 0 22

Snack 1 cup raw carrots 25 5 2 0 36.6 97 42

2 Tbsp Hummus 70 4 2 5 0 130 26
Water- 10oz
Dinner Whole wheat Penne pasta – 1 180 49 0 9 240 0 116
cup
1/3 cup light cream 160 5 0 16 0 53 61
2/3 cup low sodium chicken stalk 11 0 0 1 131 17 45
1 slice turkey bacon 30 0 3 2 0 130 128
Asparagus, steamed – ½ cup 25 5 2 0 200 13 8
1 oz parm 40 0 4 3 0 60 178
Blueberries 1 cup 60 15 0 0 114 1 18
Water- 8oz

Fluid Needs 1400cc 1300

ml
Totals 1,615 186 g 58 g 68 g 1294 1929 1977
kcal

**G.M’s favorite dishes (pizza & Carbonara) were provided with healthy modifications and appropriate
portions to ensure adherence and patient satisfaction. More fruits and vegetables were offered at meals.
For breakfast an orange was given instead of orange juice. Diet was 100kcal below calculated amount of
1700kcal/day which may further be beneficial for weight loss. The protein was below the amount calculated
of 67g protein which actually may be more benficial, could increase protein # given if concern as rises.
Potassium, sodium and phosphorous were all below 2g.

References:

1. Mahan, L. Kathleen., Sylvia Escott-Stump, Janice L. Raymond, and Marie V. Krause. Krause's
Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier/Saunders, 2012.
2. “Bell's Palsy - What Is Bell's Palsy? What Causes It?” WebMD, WebMD,
www.webmd.com/brain/understanding-bells-palsy-basics. Accessed March 31, 2019.
3. Academy of Nutrition and Dietetics. (2013). Nutrition Care Manual. Retrieved from Academy of
Nutrition and Dietetics Web Site: http://nutritioncaremanual.org/auth.cfm?p=%2Find
4. Medications and Drugs. (2005-2019). WebMD. https://www.webmd.org/drugs
5. Metabolic Acidosis. National Kidney Foundation.
https://www.kidney.org/atoz/content/metabolic-acidosis. Accessed April 1, 2019
Carley Bedell
UCONN Health Center
Date: 3/28/19

6. Mineral & Bone Disorder In Chronic Kidney Disease. National Institute of Diabetes and
Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/kidney-
disease/mineral-bone-disorder. Accessed April 1, 2019.