Carle Hospital

Outpatient

Joaquin
12950
4/12/1994
65
10/29/2018

Nutrition Assessment:
This is a 30-minute face to face Medical Nutrition Therapy visit. Patient is a 24 year- old female
referred for dietary counseling by Dr. Masolak, his family doctor after being admitted to the
hospital for stage 5 CKD and kidney replacement therapy. The patient was alone.

Diagnosis and medical history: Initially, she was referred by his medical doctor to a dietitian
for help in managing her type 2 diabetes. She then had a diagnosis of CKD 3 2 years ago,
which has now progressed to stage 5. Patient’s health issues have not improved over time due
to poor diet for her condition and improper adherence to medications prescribed for diabetes,
hypertension, and CKD.

Family History: Her parents have type 2 diabetes.

Surgical History: N/A

Medications at home: Metformin, 850mg twice daily.

Weight History:
Height: 60in/152.4cm; Current weight: 170lbs/ 77 kg; current BMI is 33.2 kg/m2, Obese.
Usual Body Weight: 161 lbs./73 kg; % usual body weight: 105.6%
Ideal Body Weight: 100 lbs./45.4 kg; % ideal body weight: 160%
Adjusted Body Weight: 117.5lbs/ 53.3 kg, % adjusted body weight: 145%

Patient states she gained 4-kg, which is due to edema, in the past 2 weeks, and she currently
weighs 170 lbs. Her BMI of 33.2 classifies her as obese and a sign of excessive energy intake.
Prior to her recent weight gain she weighed 161.2 lbs. No information on waist- hip ratio was
given.

Food and Nutrition Related History: Mrs. Joaquin’s usual intake was reported as Breakfast:
cold cereal, bread or fried potatoes, an occasional fried egg, and coffee. For lunch she has a
bologna sandwich, potato chips, and coke. Dinner consists of chili con carne, Indian fry bread,
and iced tea. Mrs. Joaquin also commonly snacks on crackers and peanut butter.

Patient has complained of anorexia which has lead to poor food intake. She also stated that she
tried to follow the diet she was given 2 years ago after her diagnosis of CKD Stage 3 but had a
hard time adhering to the diet. Her consumption of carbohydrates is high and her protein, fruit
and vegetable, and fluid intake is low.

Activities and Function: Poor physical activity levels.

Social history: N/A

Labs and tests:
Lower than ideal lab values: Calcium (8.2 mg/dL), BUN/ creatinine ratio (5.75), GFR (4
mL/min/1.73 m^2), Sodium (130 mEq/L), Total Protein (5.9 g/dL), albumin (3.3 g/dL), and
Hemoglobin (10.5 Hgb, g/dL).

Higher than ideal lab values: BUN (69 mg/dL), Creatinine (12.0 mg/dL), Potassium (5.8 mEq/L),
Phosphorus (6.4 mg/dL), Glucose (282 mg/dL), HgbA1c (9.2 %), serum cholesterol (220
mg/dL), and serum triglycerides (182 mg/dL).

Normal lab values: HDL (72 mg/dL) and LDL (111 mg/dL) cholesterol.

Blood pressure: 220/80 which is very high and classified as Stage 4 Hypertension.
Pt. has a I/VI systolic ejection murmur in the upper-left sternal border.

Some of the main health issues related to her lab values include her HgbA1c levels which are
high/diagnostic of her type 2 diabetes and indicate that her blood glucose levels have not yet
been controlled. Her very high blood pressure also puts her at high risk for developing
numerous comorbidities such as CVD and stroke that are associated with hypertension.

Current Meds: She is taking Metformin, but admits to not taking her prescribed hypoglycemic
agent and she has never filled her prescription for anti-hypertensive medication.

Nutrition Diagnosis:

Inadequate Protein Intake (NI-5.6.1) related to poor diet compared to what is recommended for
her stage 5 CKD diagnosis as evidenced by patient’s diet history, albumin level of 3.3 g/dL, and
low total protein lab values.

Obese Class 1 (NC-3.3.3) related to poor diet and lack of disease state control as evidenced by
inability to adhere to prescribed diet plan, recent weight gain, BMI, worsened state of her CKD,
hypertension, and continual lack of control of her type 2 diabetes.

Nutrition Intervention:
Nutrition Prescription
1. 1,866 kcals per day (35 kcal/kg ABW) = (35 kcals x 53.3 kg)
2. 64- 80 g protein per day (1.2-1.5 g/kg ABW) = (1.2 g/kg x 53.3 kg- 1.5 g/kg x 53.3 kg)
3. 750-1,000 ml fluid per day (750 – 1,000 ml)

A diet that is low in saturated fats and added sugars, and high in fiber, includes 2 cups each of
fresh fruits and vegetables, high amounts of lean protein is recommended for this patient
everyday. Her CKD, hypertension, and diabetes conditions make her diet very specific. She
needs to ensure that she is consuming carbohydrates at an even level throughout the day to
control her blood glucose levels, and since her kidneys are working at a very inefficient rate they
do not filter and process nutrients properly. She therefore needs to consume higher amounts of
energy and high biological value protein to ensure she does not become malnourished while not
consuming an excess of sodium which would worsen her hypertensive state as well as increase
her edema.

Implementation of Intervention
This intervention will be implemented by educating Mrs. Joaquin both when she is in the
hospital and how to self monitor her food intake once she returns home. Since the patient has 3
diagnoses that alter her nutrition prescription, education will be implemented slowly over time
during each visit so that the patient is not overwhelmed by too much new information and with
the intent of increasing adherence to the new diet plan. This education is important for long-
lasting lifestyle modification.

Dietitian Assessment/Patient Response to Intervention

Excellent. Patient seems willing to follow recommendations discussed at this appointment and
verbalized understanding.

Education Materials Provided

1. A handout that quantifies the carbohydrate content of common carbohydrate- rich foods so
that she can learn how many carbs are in the food she frequently consumes. This will educate
her on how to best manage her blood glucose levels at home.
2. Education and an informational guide on CKD management and what diet plans are best for
someone in stage 5 CKD/ kidney transplant.
3. Education and an informational handout on the importance of consuming a low sodium diet to
aid in the management of her CKD and hypertensive conditions.

Referrals and RD Follow Up Plan for Monitoring and Evaluation

Patient will be visited by an inpatient dietitian during her hospital stay and will be referred to an
outpatient renal dietitian upon her discharge from the hospital. The patient will be seen twice
weekly during her hospital stay to monitor daily food intake, lab values, and progress with her
kidney –replacement therapy. Patient was provided with contact information and was
encouraged to call with any additional questions. Patient was agreeable with this plan. At follow
up meetings patient’s weight is expected to begin to decrease and blood pressure and blood
glucose labs will improve, pending her adherence to the discussed diet plan and proper
medication use. Her CKD symptoms should also get better post kidney-replacement therapy.
Retention of nutrition knowledge that was discussed initially will be evaluated via questioning by
the dietitian. The patient will also be asked to bring a food log of her usual daily food intake to
the outpatient counseling sessions to assess adherence to the nutrition prescription. A
permanent reduction in weight and adherence to the proper diet will be the ultimate goal for Mrs.
Joaquin so we know we are properly doing whatever we can to keep her healthy in the midst of
her CKD 5, hypertension, and type 2 diabetes disease state.

Medical Nutrition Therapy provided using the 2018 evidence based practice guidelines from the
American Academy of Nutrition and Dietetics.

Christine Moody