Gordon Feldman (End-stage renal disease (ESRD),

Peritoneal dialysis, Peritonitis)

Nutrition Assessment

Client history:

- Mr. Ahmadi is a 43-year-old male with significant past medical history of ESRD on peritoneal
dialysis, hypertension is presented to ER this morning with abdominal pain that is
progressively getting worse in the last 2 days. Patient reports that his abdominal pain is
associated with intermittent nausea, vomiting, and diarrhea. Patient reports that he is having
about 5-6 episodes of loose stools per day- denies noticing any mucus / blood in the stool.
Patient reports that he was not able to have peritoneal dialysis yesterday because of
abdominal pain.
- Medical History: GERD, HIV, hypertension, renal disease - ESRD on peritoneal dialysis
(PD), other - diverticulitis
- Psychiatric History: Yes: anxiety
- Past Family History: No autoimmune disease, No blood disorders, No cancer, No cardiac
disorders, No diabetes, No gastrointestinal disorder, Yes hypertension, No neurologic
problems, No psychiatric problems, No renal disease, No respiratory disorders, No thyroid
disease, No other family illness
- Social History
- Patient Lives With: Spouse
- Smoking Status: Current some day smoker
- Tobacco type: Cigarettes, Cigars
- Alcohol Use Type: Beer
- Drug Use Type: Denies
- Home Medications
- Darunavir Ethanolate [Prezista] 800 mg PO WSUP
- Labetalol HCl [Trandate] 200 mg PO DAILY
- NIFEdipine [Nifedipine ER] 60 mg PO BID
- Abacavir [Ziagen] 300 mg PO BID
- Ritonavir [Norvir] 100 mg PO WSUP
- Sodium Bicarbonate 667 mg PO TIDAC
- Calcium Acetate [Phoslo] 1,334 mg PO TIDWM
- Lamivudine [Epivir] 50 mg PO DAILY
- B Complex & C No.20/Folic Acid [Renal Caps Softgel] 1 mg PO DAILY
- ALPRAZolam [Xanax] 0.25 mg PO BID PRN
- Cinacalcet HCl [Sensipar] 60 mg PO DAILY
- Paricalcitol [Zemplar] 2 capsule PO DAILY
- Inpatient Medications:
- Acetaminophen (Tylenol) 650 mg PO Q6H PRN Reason: Pain Rated 1-3 (Mild Pain)
- Hydrocodone Bitart/Acetaminophen (Norco) 1 each PO Q4H PRN Reason: Pain Rated 4-7
(Moderate Pain)
- Alprazolam (Xanax) 0.25 mg PO BID PRN Reason: Anxiety
 - Aspirin (Ecotrin) 81 mg PO DAILY SCH
- Calcium Acetate (Phoslo) 1,334 mg PO TIDWM SCH
- Cinacalcet (Sensipar) 60 mg PO DAILY SCH
- Ciprofloxacin (Cipro 500 Mg/5 Ml) 250 mg PO Q24H SCH
- Darunavir (Prezista) 800 mg PO WSUP SCH
- Enoxaparin Sodium (Lovenox) 40 mg SUBQ DAILY SCH
- Hydromorphone HCl (Dilaudid) 1 mg IV Q4H PRN Reason: Pain Rated > 7 (Severe Pain)
- Cefepime HCl 1 gm/ Sodium (Chloride) 100 mls @ 200 mls/hr IVPB Q12H SCH
- Dextrose (Dextrose 5%-Water Iv Soln) 1,000 mls @ 60 mls/hr IV .Q16H40M SCH
- Labetalol HCl (Trandate) 200 mg PO DAILY SCH
- Nifedipine (Procardia Xl) 60 mg PO BID SCH
- Paricalcitol 2mcg Caps (Patient Using Own Meds) 0 capsule PO DAILY SCH
- Ondansetron HCl (Zofran) 4 mg IV Q4H PRN Reason: Nausea
- Ritonavir (Norvir) 100 mg PO WSUP SCH
- Sodium Bicarbonate (Sodium Bicarbonate) 650 mg PO TIDAC SCH
- Vitamin B Complex/Folic Acid (Nephrocaps Softgel) 1 capsule PO DAILY SCH

Biochemical data, medical tests and procedures:

- Current Labs
- CBC
- HGB 11.4 L
- HCT 35.4 L
- WBC 9.4
- PLT 188
- RBC 4.19 L
- MCV 84.5
- MCH 27.3
- MCHC 32.3 L
- RDW 17.3 H
- MVP 8.4
- CMP
- NA 144
- K 5.3 H
- CL 109 H
- CO2 23
- ANION GAP 12
- BUN 87 H
- CRT 13.8 H
- EST GFR (AFRICAN) 5 L
- EST GFR (NON-AFRICAN) 4 L
- BUN/CRT 6.3 L
- CALC OSM 313 H
- CA 9.5
- TOT BILI 0.3
 - AST 27
- ALT 18
- C-REACTIVE PROTEIN <0.5
- TOTAL PROTEIN 7.4
- ALBUMIN 4.0
- GLOBULIN 3.4
- HCO3 23
- GLUCOSE 84

Anthropometric measurements:

- 99.7kg (219lbs), 1.78m (5’10) 52 year old, BMI: 31.5

- IBW: 166lbs, 75.45kg

Physical exam finding (nutrition focused):

- Cardiovascular exam: Present: RRR, +S1, +S2

- GI/Abdominal
- GI/Abdominal exam: Present: guarding, normal bowel sounds, tenderness - diffuse
- All other systems reviewed were normal
- *no edema was noted

Food and nutrition history:

- No data was given

Comparative standards:

- Renal dietitian- to provide an adequate diet order that will help the patient manage
symptoms/progression of his various diagnoses
- Physician- to assess overall wellbeing and prioritize health concerns that are most important
and treat them first (or refer out)
- Gastroenterologist - to assess gastrointestinal function and treat current digestive issues
such as diverticulitis
- Nurse - to administer medications, check on patient and ensure current diet order is being
followed along with checking patient’s symptoms regularly
- Nephrologist- to perform dialysis and assess kidney function
Total energy estimated needs:

- (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) + 5

- 997 + 1,111 - 260 + 5 = 1.853 x 1.2AF = 2,224 calories
- PD: 30-35 kcals/kg IBW
- 2,263.6 - 2,641 calories
- Average: ​2,400 calories

Total protein estimated needs:

- PD: 1.2-1.5 grams per kg IBW

- 90.54- 113 grams (​100 grams protein​)

Total fluid estimated needs:

- 750-1000 mL per day plus urine output

- Output = 1873 + 750 = 2,623
- + 1000 = 2,873
- Average: ​2,700mL fluids

Sodium​:

- 1.5-4 grams/day

Potassium​:

- 3-4 grams/day

Phosphorus​:

- .8-1.2 grams/day

Nutrition Diagnosis

(P) Problem:
 - Altered nutrition related lab values (kidney disorder)

(E) Etiology (r/t):

- Related to acute exacerbation of diverticulitis and uncontrolled kidney failure

(S) S/S (aeb):

- As evidenced by high BUN and creatinine as well as an extremely low GFR

Nutrition Intervention

Food and/or Nutrition Intake ND, Nutrition Education E, Nutrition Counseling C, Coordination of
Nutrition Care RC, Population Based Nutrition Action P

Nutrition prescription:

- Regular diet consisting of 2,400 calories, 100 grams of protein, >30 grams fiber, 2,700mL
fluids, 2 grams sodium, 3 grams potassium, and 1 gram phosphorus.

Intervention:

- Sodium and fluid controlled diet for kidney failure as well as nutrition education on how to
consume an adequate diet (at home) for his condition.

Goal:

- To consume the recommended sodium and fluid controlled diet and stabilize lab values.

Nutrition Monitoring and Evaluation

Indicator:

- Follow up with RDN in two days to see a change in lab values and to see that the patient is
consuming the diet recommended for him as well.
Criteria:

- Specified lab values will normalize (normal for ESRD patient) ​and patient will feel better
physically.

Youssef Ahmadi (ESRD)

Nutrition Assessment

Client history:

- General Med-H&P: History of Present Illness

- Chief complaint HPI: abdominal pain
- The patient is a 43 yom with a history of TIA, HIV, HTN, GERD, diverticulitis and ESRD on
PD who presented to the ER with c/o abdominal pain, nausea, vomiting and diarrhea which
all began yesterday. He has chronic abdominal pain with history of several negative CT
scans and has been evaluated for peritonitis in the past but has never had confirmed
infection. He missed his dialysis yesterday due to pain. He admits to occasional chest pain
and shortness of breath as well. Received morphine in the ER but this hasn't helped his pain
and actually may have made it worse. He has been started on empiric antibiotics in the ER.
Has been on peritoneal dialysis for 2 years and was on hemodialysis for a few years prior to
that.
- General Med-H&P: PMH
- Source: obtained from patient, old records reviewed
- Medical History: GERD, HIV, hypertension, renal disease - ESRD on peritoneal dialysis
(PD), other - diverticulitis
- Psychiatric History: Yes: anxiety
- Family History
- Past Family History: No autoimmune disease, No blood disorders, No cancer, No cardiac
disorders, No diabetes, No gastrointestinal disorder, Yes hypertension, No neurologic
problems, No psychiatric problems, No renal disease, No respiratory disorders, No thyroid
disease, No other family illness
- Social History
- Patient Lives With: Spouse
- Smoking Status: Current some day smoker
- Tobacco type: Cigarettes, Cigars
- Alcohol Use Type: Beer
- Drug Use Type: Denies
- Home Medications
- Darunavir Ethanolate [Prezista] 800 mg PO WSUP
- Labetalol HCl [Trandate] 200 mg PO DAILY
- NIFEdipine [Nifedipine ER] 60 mg PO BID
- Abacavir [Ziagen] 300 mg PO BID
- Ritonavir [Norvir] 100 mg PO WSUP
 - Sodium Bicarbonate 667 mg PO TID AC
- Calcium Acetate [Phoslo] 1,334 mg PO TIDWM
- Lamivudine [Epivir] 50 mg PO DAILY
- B Complex & C No.20/Folic Acid [Renal Caps Softgel] 1 mg PO DAILY
- ALPRAZolam [Xanax] 0.25 mg PO BID PRN
- Cinacalcet HCl [Sensipar] 60 mg PO DAILY
- Paricalcitol [Zemplar] 2 capsule PO DAILY
- Vaccination history: Pneumococcal polysaccharide (PPSV) at age 43, Tdap at age 41,
Receives annual influenza vaccine
- Allergies: ACE Inhibitors Severe allergy, SOB

Biochemical data, medical tests and procedures:

- Current Labs
- CBC
- HGB 11.4 L
- HCT 35.4 L
- WBC 10.7 H
- PLT 188
- RBC 4.19 L
- MCV 84.5
- MCH 27.3
- MCHC 32.3 L
- RDW 17.3 H
- MVP 8.4
- CMP
- NA 145
- K 5.3 H
- CL 98
- CO2 23
- ANION GAP 12
- BUN 87 H
- CRT 13.8 H
- EST GFR (AFRICAN) 5 L
- EST GFR (NON-AFRICAN) 4 L
- BUN/CRT 6.3 L
- CALC OSM 313 H
- CA 9.5
- TOT BILI 0.3
- AST 27
- ALT 18
- C-REACTIVE PROTEIN 6.5 H
- TOTAL PROTEIN 6.4
- ALBUMIN 3.0 L
- GLOBULIN 3.4
 - HCO3 23
- GLUCOSE 95

Anthropometric measurements:

- 99.7kg (219lbs), 1.78m (5’10) 43 year old, BMI: 31.5

- IBW: 166lbs, 75.45kg

Physical exam finding (nutrition focused):

- Vitals: 99.3, 105, 20, 156/83, 96%

- Biometric results: 1.78m, 99.7kg, BSA 2.22m2, BMI 31.5kg/m2
- Constitutional
- General appearance: Present: cooperative, mild distress
- Head exam: Present: atraumatic, normocephalic
- Eye exam: Present: EOMI, PERRL
- ENT exam: Present: mucous membranes dry, normal external ear exam
- Respiratory exam: Present: CTAB, nonlabored. Absent: rhonchi, wheezes, rales
- Cardiovascular exam: Present: RRR, +S1, +S2
- GI/Abdominal exam: Present: guarding, normal bowel sounds, tenderness - diffuse
- Extremities exam: Present: normal inspection. Absent: pedal edema, tenderness
- Neurological Exam
- Neurological exam: Present: alert, CN II-XII intact, oriented X3
- Skin exam: Present: warm, dry, reduced skin turgor

Food and nutrition history:

- 24 hour recall showed an unremarkable diet (no major concerns). No note on whether or not
he has seen a dietitian before

Comparative standards:

- Renal dietitian- to provide an adequate diet order that will help the patient manage
symptoms/progression of his various diagnoses
- Physician- to assess overall wellbeing and prioritize health concerns that are most important
and treat them first (or refer out)
- Gastroenterologist - to assess gastrointestinal function and treat current digestive issues
such as diverticulitis
 - Nurse - to administer medications, check on patient and ensure current diet order is being
followed along with checking patient’s symptoms regularly
- Nephrologist- to perform dialysis and assess kidney function

Total energy estimated needs:

- (10 × weight in kg) + (6.25 × height in cm) - (5 × age in years) + 5

- 997 + 1,112 - 215 + 5 = 1,899 x 1.2AF = 2,279 calories
- PD: 30-35 kcals/kg ​IBW
- 2,263.6 - 2,641 calories
- Average: ​2,400 calories

Total protein estimated needs:

- PD: 1.2-1.5 grams per kg IBW

- 90.54- 113 grams (​100 grams protein​)

Total fluid estimated needs:

- 750-1000 mL per day plus urine output

- Output = 1873 + 750 = 2,623
- + 1000 = 2,873
- Average: ​2,700mL fluids

Sodium​:

- 1.5-4 grams/day

Potassium​:

- 3-4 grams/day

Phosphorus​:

- .8-1.2 grams/day
Nutrition Diagnosis

(P) Problem:

- Altered nutrition related laboratory values

(E) Etiology (r/t):

- Related to unmanaged kidney failure

(S) S/S (aeb):

- As evidenced by ↑ BUN, ↑ Cr, ↓GFR.

Nutrition Intervention

Food and/or Nutrition Intake ND, Nutrition Education E, Nutrition Counseling C, Coordination of
Nutrition Care RC, Population Based Nutrition Action P

Nutrition prescription:

- NPO until nausea and vomiting subside. Clear liquids (within limit) thereafter, then full liquid
as tolerated, then regular.
- Regular diet consisting of 2,400 calories, 100 grams of protein, >30 grams fiber, 2,700mL
fluids, 1.5 grams sodium, 3 grams potassium, and 1 gram phosphorus.

Intervention:

- Sodium modified diet (decreased) with fluid restriction.

- Nutrition education on new diet and why it is important to follow to manage symptoms of
ESRD.

Goal:

- To decrease fluid retention (rid the patient of ascites) and alleviate symptoms of ESRD.
Nutrition Monitoring and Evaluation

Indicator:

- Patient will have less fluid retention, related lab values will return to within “normal” ranges
and symptoms of ESRD will be alleviated at least somewhat by the next visit.

Criteria:

- Patient will follow recommended diet order and follow up with dietitian in two days to see
improvement in specified areas (labs, fluid retention, and other related symptoms).