Report Eight : CLINICAL CASE STUDY

20 Points
Provide your text in bold face in the spaces below. Feel free to add space as needed. Bullet
point explanations are fine. Choose a patient diagnosed with any chronic disease you studied in
NUTR 424 (diabetes, heart disease, renal failure, metabolic syndrome, hypertension, etc.)
Discuss the related pathophysiology of your patients condition and rationale of the MNT
prescribed.
The patient was diagnosed with the chronic disease, renal failure and is hospitalized due to
her end stage renal disease. The pathophysiology of end stage renal disease is when the
kidneys are unable to excrete waste products, maintain fluid and electrolyte balance and
produce hormones. As renal failure progresses the level of circulating waste products build
up and due to the unacceptable levels lead to symptoms of uremia. Symptoms of uremia
include malaise, weakness, nausea and vomiting, muscle cramps, itching and metallic taste
in month and neurologic impairment. End stage renal disease is irreversible but can be
managed by the treatment of dialysis or kidney transplantation. Patients that reach end
stage renal disease usually have chronic hypertension, diabetes mellitus and
glomerulonephritis. This patient has chronic hypertension.
The reason the RD was consulted for this patient was by an RN referral for weight loss.
The MNT prescribed was to have a supplement in between meals. The RD recommended
Novasource Renal Qmeals, an oral supplement that is a high calorie fluid concentrated for
patients with chronic kidney disease on dialysis or electrolyte/fluid restriction. The
rationale behind the supplement was to maintain good nutrition status by using the oral
supplement to receive adequate protein, energy, vitamin and mineral intake. The patient
was recommended a puree/renal diet. The rationale behind the puree diet was due to her
inability to swallow and digest food after a swallowing test was done by a speech therapist.
Interpret relevant biochemical indicators (laboratory values).
Renal function panel results;
The patients relevant biochemical indictors were GFR 6, creatinine of 4.10 BUN of 62,
Albumin of 2.4.
GFR- The Glomerular flirtation rate tells us how well the kidneys are working. The
patients glomerular filtration rate was 6 compared to the normal range of 61-714 ml/min
for a African American. This indicated that the patient is in Kidney failure. Once the rate
is below 15ml/min it is classified as end stage renal diseases. The number means that the
patients kidneys are no longer properly functioning in filtering blood.
Creatinine-The patients creatinine level was high at 4.10 compared to the normal range
being between 0.60-1.20 mg/ dl. This indicates that the kidneys are not functioning
properly to clear creatinine. Creatinine is a normal waste product of protein breakdown.
The normally functioning kidneys are able to take out creatinine from the blood and pass it
out through urine. The high number tells us that creatinine is building up in the blood
because the kidneys are unable to pass it out through urine and the patient is in need of
dialysis. The patient is also currently losing weight, which is breaking down more muscle,

making the creatinine level higher.

BUN- The patients BUN was 62 compared to the normal range of 8-25 mg/dl; this indicates
that the kidneys are not properly functioning to remove nitrogenous waste. Since BUN is
high along with creatinine these lab values indicate her disease state of end stage renal
disease. However because the patient is currently on hemodialysis, the lab value is
appropriate for someone on dialysis.
Albumin-The patients albumin was low at 2.4 compared to the normal range of 3.2-5.2
g/dl; this indicated that the patient is not receiving adequate protein. This lab value makes
sense because the patient is not eating due to her swallowing difficulties and having kidney
disease.
Assess weight status in %IBW and BMI terms
The patients weight is 60kg or 132 pounds and is 63 inches tall.
IBW is 115 pounds or 52.3kg (calculation was 100Ibs+ 5Ibs for every inch)
IBW % is 114 % (actual weight/ IBW*100%) in IBW% this patient is considered to be
overweight in terms of the IBW% standards. Even though the patient is considered
overweight in %IBW I would not be concerned because the patient has lost 25 pounds in
the past month; and due to her age and calorie needs I feel the percentage is an
inappropriate marker to say she is overweight.
BMI 23.4 and in BMI standards is considered to be in the healthy range. (Ibs body weight*
705/ inches^2)

Create a table which includes prescribed medications THAT RELATE TO THE PATIENTS
CHRONIC DISEASE. Include mechanism for action and possible side effects.
Medication
Venofer

Nephrocap
Kayexalate

Fosamax

Mechanism of action
Venofer is administrated
intravenous, it dissociates
into iron and sucrose. The
iron is transported as a
complex and targets cells
including erythroid
precursor cells, to increase
iron needs.
Vitamin supplement.
It partially releases sodium
ions and binds excess
potassium carrying out of
the body.
Inhibits the enzyme in the
osteoclast while leads to the

Possible side effects

headache, abdominal pain,
dyspnea, hypotension,
diarrhea, trouble breathing

Diarrhea and nausea.

Coughing, shortness of
breath, stomach pains,
nausea, sore throat.
Stomach pain, irritation or
pain of the esophagus,

Sensipar

Sevelamer

suppressing of osteoclastic
bone resorption and
reduction of bone turnover.
lowers parathyroid
hormone (PTH) levels by
increasing the sensitivity of
the
calcium-sensing receptor to
extracellular calcium.
Binds phosphate to prevent
increased blood phosphate
levels.

cough and vomiting.

Decreased urine output,

blurred vision, weight loss,
decreased appetite, nausea
and vomiting.

Frequent urination, dry

mouth.

Calculate your patients total energy expenditure (TEE). Include a complete rationale for your
calculations.
I calculated the patient to have a total energy expenditure of 2100 kcal/d. I did 35 kcal/kg*
60 kg of actual body weight instead of IBW. I choose 35 kcal/kg of actual body weight
because the patient is currently on hemodialysis and is losing weight due to her decreased
appetite and difficulties swallowing. I choose not to use the IBW because I feel she would
benefit from the extra calories to help gain back some weight she lost and keep her from
losing more.

Identify nutrition education needs of your patient

Patient needs to be educated about the renal diet, because she said she does not know which
foods to consume and which to avoid.
Patient needs to be educated about her disease state of end stage renal disease. Needs to
understand the treatment of hemodialysis and its effects.
Patient needs to be educated on the importance of eating and the reasoning behind the use
of oral supplements in between meals.

Identify obstacles to dietary adherence.

Biggest obstacle is the patients inability to swallow food without choking.
Patient refused to drink the oral supplements because she did not like the taste. This is
concerning because patient has already lost 25 pounds in a month, has decrease albumin
levels and keeps losing weight.
Patient refused to eat because she still felt like she was choking even with modified diet.
This is an obstacle because patient refuses to go on tube feeding. Patient is not getting
enough calories because of her avoidance of food.

Formulate 2 PES statements for your patient.(Use standardized language diagnostic codes).

Altered nutrition related laboratory values (NC-2.2) related to disease state of end stage
renal disease as evidence by lab values of BUN 62 mg/dl, creatinine 4.10 mg/dl and GFR 12
ml/min, recent weight loss and history of renal failure.
Swallowing difficulty (NC-1.1) related to prior mechanical ventilation as evidence by
patients comments of feeling like Im going to choke after eating:, ever since I was taken
off ventilation I have pain while swallowing, avoidance of food and weight loss
Write and ADI note for this patient using the PES statements you have formulated.
NEED NOTE FORM1!!!

Heading
A

PES
#1

PES
#2

Date, Time, and Department

Pt comments she has no appetite to eat
every time I do eat I feel like Im going to choke
ever since I was taken off ventilation I have pain while swallowing
Pt reports weight loss of 25# in past month
68 y/o female
Ht: 63in wt: 74.6kg=168# IBW: 52.3kg= 115# BMI: 30, UBW%: 71%
TEE: 2100Kcal (35kcal/ ABW* 60kg)
Med Hx: HTN, Chronic Obstructive Lung disease, ESRD, Rheumatoid
arthritis, Osteoporosis, CHF
Physical defects: Kyphosis
Family Hx: HTN, CHF, CKD
Meds: Advair, Albuterol Sulfate, Aspirin, Colace, Carvedilol
Lab values: GFR 12ml/min, creatinine of 4.10mg/dl, BUN 62mg/dl, Albumin
2.4.

Altered nutrition related laboratory values (NC-2.2) related to disease state

of end stage renal disease as evidence by lab values of BUN 62 mg/dl,
creatinine 4.10 mg/dl and GFR 12 ml/min, recent weight loss and history of
renal failure.

Swallowing difficulty (NC-1.1) related to prior mechanical ventilation as

evidence by patients comments of feeling like Im going to choke after
eating:, ever since I was taken off ventilation I have pain while

swallowing, avoidance of food and weight loss

I
1. Nutrition Prescription (NP1.1)
A. Recommend 2100 kcal/d, 63 g/d of protein, 41g/d of phosphorus,
2000mg/d Na, 3000mg/d Potassium, 2000ml liquid intake per day,
puree/renal diet and oral supplement intake of Novasource Renal
Qmeals.
2. Nutrition Education (E-1)
A. Educate patient about her disease state and why it is important to
consume calories
3. Collaborate and Referral of Nutrition Care (RC-1)
A. Collaborate with speech therapist in order to help patient with
swallowing difficulties.
B. Collaborate with social worker in order to provide information
about nursing home options.
4. Work with the patient and have her try all the different flavors of the
oral supplements available in order to find out which one she likes
the best.
I(M/E)
Monitor patients weight, BUN, CRT values during next follow up
Evaluate patients intake of food and preference of oral supplement
Follow up with collaboration of speech therapist and social worker to ensure
patient is receiving help.
Signature Melissa Hayden