Terese Wallace

Nutrition First Office Call

Client Name: HD
Appointment length: 50

DOB: 04/17/1943

Age: 70yo

Client History
Reason for visit/HPI: Nephrologist referral for renal diet r/t ESRD and recent need for hemodialysis
3 d/wk. Has had diet education class but doesn't remember much.
PMH: DM2 10+ y, dx at 60 yo. HTN. Tooth loss (wears dentures).
Family Med Hx: No information
Allergies: NKA
Tobacco/Drug Use: Quit smoking 5 years ago. No ETOH. No drug use.
RX/OTC: Dialysate 3x/w, Atenolol, Erythropoeitin (Labs seem to indicate pt not taking EPO.), Miralax,
Sertraline, Ferrlecit, Lantus, Nephrocaps, Zemplar, Tums (I hate the taste of those Tums and pt
forgets to take them with meals).
Physical activity: Inactive/mostly housebound. In-center hemodialysis.
Social Hx: Lives alone on fixed income. Daughter/Access ride provide transportation to medical
appts. Adult daughter lives nearby: attentive, shops for groceries, occasionally provides meals,
accompanied father to appt.
Food and Nutrition History
24 hour recall:
S when he wakes/time varies: 1 cup coffee with 2 Tbsp half and half.
B (11 a.m.) 1 cup orange juice, 2 slices toast with butter, handful of M&Ms.
L (1 pm): 2 cups canned tomato soup, 12 saltine crackers, 1 oz sliced cheddar, and 1 cup 2% milk.
D (8 pm): Hungry Man TV dinner: Salisbury Steak with mushroom/onion gravy, mashed potatoes,
green beans, and brownie, 1.5 cups iced tea.
S (10 pm): 1 cup chocolate ice cream:
NIA (Food Processor, % calculated for dry wt/hemodialysis): 2177 kcal (84% RDI), 71 g pro (86%
RDI), 253 g CHO (71% RDI), 100 g fat (123% RDI: sat 213%, 3 fa 40%, 6 fa 21%), 18 g fiber
(51% RDI), 7.5 c fluid (188% RDI), 3769 g Na+ (188% RDI), 2006 g K+ (83% RDI).
Dietary preferences: canned soup (esp tomato), frozen dinners (esp Hungry Man Salisbury Steak) .
Weight History: Current dry wt/IBW: 153 lbs(69.4 kg). Wt 1 year ago: 170 lbs (77.1 kg). Wt 3 months
ago/pre-dialysis: 159 lbs (72.1 kg). 9m wt change (pre-dialysis) 6% (11 lb/5kg). 12 m wt change
(pre-dialysis to dry wt post-dialysis: 10% (17/7.7 kg): Significant.
Meals away from home: likely to be seldom
Who prepares food: self (canned/frozen heat and eat meals), daughter occasionally provides meals
Where shops for food: Grocery Outlet, Safeway
Other nutrition notes: Reports that lately he doesn't have much appetite. Typically skips breakfast.
Ill-fitting dentures. Doesn't reliably take meds. Daughter describes pt as set in his ways.
Physical Findings
GI Function: Chronic constipation: BM every 23 d It doesnt bother me much.
Sleep hx: Reports feeling fatigued/not sleeping well. Nods off during appt. I sleep a lot at dialysis so
I cant sleep at night very well plus I get a lot of muscle cramps which keeps me awake.
Energy: Very low
Stress: No reports of stress.
Overall clinic observation: Slow movements/reaction time, edema in ankles, unfocused.

Terese Wallace

Biochemical Data
BUN 20 mg/d: Low; Creatinine 2.8 mg/dL: Low (GFR: 28.9 mL/m: Low); FBS 140 mg/dL: WNL;
HbA1C 7.2%: ~WNL; 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/mL: Low; TIBC 455 mcg/dL: High; Transferrin 366 mg/dL: High; Triglycerides 244 mg/dL: High;
Total Cholesterol 190 mg/dL: WNL
Other: BP: 143/92 mmHg: High; Urine output = 1 cup (240 mL).
Anthropometrics
Height: 70 in (1.8 m)
Weight: Dry wt: 153 lbs (69.4 kg). Current wt (post-dialysis: 160 lbs (72.6 kg). (See wt hx above.)
BMI at dry wt: 22 (WNL)
Estimated Needs / Nutrition Prescription
REE/ Kcals: 35-40 kcals/kg = 24002800 kcals/d
Protein (g/kg): 1.2 g/kg = 83 g/d (3 oz/d)/ 50% HBV protein: 42 g/d (1.5 oz/d)
Fluids: urine output/1 cup (240mL) + 3 cups (10l mL) = 4 cups (950 mL)/d
Other: Potassium: 2-3 g/d. Sodium: < 2 g/d
Nutrition Diagnosis
Problem 1 Excessive Fluid Intake (NI 3.2)
Etiology: r/t food- and nutrition-related knowledge concerning appropriate fluid intake
Signs & Symptoms: AEB edema; HTN (143/92); post-dialysis wt of 160 lb (7 lb > dry wt; dietary
recall of 7.5 cups fluid (188% 4 cup fluid/d RDI), 3769 g Na+ (188% RDI)
Problem 2 Excessive Potassium Intake (NI 5.10.5)
Etiology: r/t lack of knowledge about management of ESRD requiring K+ restriction.
Signs & Symptoms: AEB lab showing hyperkalemia: K+ of 6.4 mEq/L (3.5-5.5 mEq/L WNL for
dialysis pt), and estimated intake of foods containing >250 mg K+/serving.
Nutrition Intervention 1:
Nutrition Education-Content: E-1.5: Recommended modifications
Reviewed importance of managing HTN/ fluid/Na+ role in HTN & dialysis. Described fluids that count
toward intake (beverages/soup/gravy/ice cream). Educated pt about need to Na+ to thirst.
Reviewed Na+ in processed foods. Stressed 4 cup/d limit. Introduced diary to track fluid intake/thirst.
Goal: On f/u in 2 days, pt will report fluid intake of not more than 4 cups.
Nutrition Intervention 2:
Nutrition Counseling: E-1.4 Nutrition relationship to health disease
Alerted, without alarming, pt/daughter on heart attack risk with hypercalemia. Talked about K+ role in
HTN. Discussed K+ foods (esp potatoes/tomatoes/ mushrooms). Talked about foods with <250
mg/serving - gave examples. Warned against salt substitutes.
Goal: On f/u in 2 days, pt will list several low K+ foods he could substitute for high K+ foods.
Followup: Assess goal attainment/review diet diary for fluid 4 cups/day and thirst levels and ideas
for K+ food substitutions. Shopping/meal planning ideas. Review bp goals. Talk about calories
needs to prevent wasting/HBV protein sources to preserve lean muscle mass. Talk about PO4 and
need to ward off metabolic bone dz (discuss grinding up Tums and putting in/on food.) Stress imp of
taking regularly taking prescribed meds/avoiding OTC supplements. Look at National Kidney
Foundation web site.