Nutrition First Office Call

Pt Initials:
HD

Appointment length:
60 min

ASSESSMENT
Client History
Reason for visit:
Nephrologist referral for implementing renal diet. Daughter present.
Personal hx:
70 yo German American M. Quit smoking 5 years ago.
Medical hx:
Dx c ESRD; recently started HD 3 x week. Dx c T2DM 10 years ago. Probably undiagnosed for several
years. Muscles cramps, ankle edema, fatigue, loose-fitting dentures.
Family Med hx:
N/A
Social hx:
Fixed income. Lives alone; one daughter, attentive and local. She takes HD to dialysis appts or he takes
Access Ride medical transport. Mostly homebound.

Food and Nutrition-Related History

Food and Beverage Intake and/or Nutrition Intake Analysis Results
: Energy intake is approximately 2112 kcal/d (80%
of ESRD guidelines). Breakfast is 1 cup of coffee with 2 tbsp half and half. Morning snack of 8 ounces orange juice and
2 slices toast with butter. Lunch is 2 cups canned tomato soup, 12 saltine crackers, 1 oz cheddar cheese, and 8 fl oz
2% milk. Dinner is a Salisbury Steak Hungry Man TV dinner with 12 fl oz iced tea and evening snack is 1 cup chocolate
ice cream. Protein intake is 74 g (89% of g/kg). CHO intake is 54% of kcal (AMDR 45-65%). Fat intake is 34% of kcal
(AMDR 30-35%). Potassium intake is 4.3 g (215% of ESRD guidelines). Sodium intake is 4.6 g (306% of ESRD
guidelines). Phosphorous intake is 876 mg (WNL). Fluid intake is 1774 mL (184% of ESRD). ~5 servings of dairy/day
(ESRD guideline is 1 serving). Skips breakfast because of sleeping in and lack of appetite. Meal pattern is two meals
and two snacks. Often eats canned or frozen meals. Denies ETOH.
Food and Nutrition History:
Took a class on renal diet but difficulty recalling information.
Knowledge/Beliefs/Attitudes/Behaviors:
Having trouble w/ diet changes. Likes frozen and canned meals, especially
tomato soup and frozen Salisbury steak.
Food Access and Preparation:
Daughter shops for pt at Grocery Outlet or Safeway; sometimes brings pt prepared
food. Pt doesnt have energy to cook but heats canned and frozen food up.
Food allergies/Intolerances
: NKFA.
Physical Activity:
N/A
Medications and Dietary Supplements:
Atenolol; EPO; Miralax; Sertaline; Ferrlecit; Latnus Basal Insulin; Nephrocaps;
Zemplar; Tums (dislikes taste and forgets to take them with meals)
Anthropometric Measurements
Height (in/cm):
70 in/178 cm
Weight (lb/kg):
153 lb/69.5 kg (dry)
BMI:
22 (normal)
Weight hx:
170 lbs 1 year ago. 159 lbs 3 mo ago. Wt before last dialysis session: 165 lbs. Wt aft last dialysis session:
160 lbs
Other measurements:
7.8% fluid gain (5.5 L) between dialysis sessions
Ideal/reference weight:
149 - 182 lb
Usual weight
: unknown, 1 year ago was 170 lbs
% Wt change: -10% in 1 year
Desired weight:
Not applicable.

%ideal/reference weight:
100%
%usual weight:
unknown, 90% of UBW from 1 year ago
Weight change classification
: of concern

Biochemical Data, Medical Tests and Procedures

Pertinent labs/tests/procedures:
Urine output 240 mL; FBS 140 mg/dL (WNL); HbA1C 7.2% (WNL); Albumin 3.0 g/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 normal); TIBC 455 mcg/dL (high); Transferrin 366 mg/dL (high);
Triglycerides 244 mg/dL (high)

Nutrition Focused Physical Exam Findings

GI Function:
Chronic C; BM every 2-3 days - not bothered too much; reduced appetite
Sleep hx:
Sleeps during dialysis so has trouble sleeping at night. Wakes up late. Woken by muscle cramps.
Energy:
Pt reports fatigue.
Stress:
N/A
Blood pressure:
143/92 (high, 5/15/15)
Overall clinical observation
: Slow in movements and rxn time and appears sleepy and nods off. Ankle edema.
Dentures that appear to fit loosely. Adult daughter present and attentive.

DIAGNOSIS
Problem:
Excessive potassium intake (NI-5.10.2.5) related to
Etiology:
difficulty implementing renal diet and decreased kidney function as evidenced by
Signs and Symptoms:
serum potassium of 6.4 mEq/L and reported potassium intake 215% of ESRD diet guidelines.
Problem:
Excessive Fluid Intake (NI-3.2) related to
Etiology:
difficulty implementing renal diet and high intake of high sodium processed foods as evidenced by
Signs and Symptoms:
5.5 L fluid gain between dialysis treatments, low serum sodium (126 mEq/L), ankle edema,
reported fluid intake 184% of ESRD diet guidelines, reported sodium intake 306% of ESRD diet guidelines.

INTERVENTION
Nutrition Prescription
REE/ Kcals:
2433 - 2780 kcal/day (35-40 kcal/kg)
Protein (g/kg):
1.2 g/kg = 83 g/day
Fluids (ml/kg):
3 cups + Urine output (240 mL) = 4 cups = 960 mL/day
Other:
K+ intake of 2 to 3 g/day; Na+ intake of 1.5 - 2 g/d; PO4 intake of 1.2 g/day (1 serving dairy/day; limit
convenience foods, prepared foods, fast foods; limit beans, nuts, bran); TUMS for Ca2+ and phosphate binding with
meals.
Intervention 1: Meals and Snacks - Mineral-modified diet - Decreased potassium diet (ND-1.2.11.5.2):
Explained
risk of cardiac arrest with excessive potassium intake with ESRD and identified tomato products as high in potassium.
Instructed pt and daughter on how to look for potassium chloride on packaged food labels especially for low-sodium
foods and provided Potassium and Kidney Disease Handout. Went through list of high, medium, and low potassium
foods with pt to identify preferences. Brainstormed affordable and convenient meal options with goal of less than or
equal to 1 serving/d of high K+ food, 2 servings/d medium K+ food, and 3 servings/d low K+ food (eg meals: tuna
salad, egg salad, chicken and penne pasta). Daughter agreed to read labels, purchase from this list, and pt agreed to
consume these foods.
Intervention 2: Nutrition Education-Content-Recommended modifications (E-1.5):
Explained relationship between
fluid intake and intake of high sodium food (canned soup and frozen dinners) and risks of excessive fluid gains.
Explained fluid intake includes drinks, soups, ice cream, & anything that melts at room temperature. Brainstormed
affordable convenient low sodium processed food options for daughter to purchase that contain <600 mg/serving and
provided Sodium: Shake the Salt Habithandout. Explored options for managing thirst such as sucking on ice chips
and sugar free hard candy, and spreading fluid intake out throughout the day. Pt agreed to try Healthy Choice Low
Sodium frozen meals (~560 mg Na+/serving) for dinner until next appointment and limit fluid intake to 960 mL (split
into 1 cup 4x day including drinks, soups, ice cream, etc).

MONITORING /EVALUATION
Professional goal #1:
To address hyperkalemia, at 2 day follow up visit, pt demonstrate intake of 2-3 grams
potassium/day as reflected by 24 hour recall.

Professional goal #2:

To address excessive fluid intake, at 2 day follow up visit, pt will demonstrate sodium intake of
1.5-2 g/d and ~960 mL of fluid as reflected by 24 hour recall.
Follow up:
COC w/dentist about dentures, Increasing kcal and protein to meet needs, low phosphate diet, correct use
of phosphate binders, COC with MD for anemia management, calcium and vitamin D levels, blood sugar regulation
Handouts provided:
Potassium and Kidney handout; Sodium, Shake the Habit handout from NW Kidney Center,
Food log for tracking meals
Clinician signature: ____________________________________________________

BASTYRCENTERFORNATURALHEALTH
NutritionTeamCare

NutritionConsultation

Name:
HD

DateofBirth:4/19/1945

Clinician:
LizSullivan

Date:
5/15/15

NutritionalRecommendations:

Thankyouforcomingintoday,HD.Herearethegoalswediscussedfortodaysvisit
on5/15/15:

Startingtoday,yourdaughterwill:
Willreadfoodlabelstocheckforpotassiumchloridecontent(especiallylow
sodiumfoods)
UsethePotassiumandKidneyDiseasehandouttopurchasemostlylow
andmediumpotassiumfoods
Willpurchaselowsodiumpackagedfoods,includingHealthyChoicefrozen
mealsfordinner
Startingtoday,Iwill:
Eatlessthanorequalto1high,2medium,and3lowpotassiumfoodsper
dayasnotedbythePotassiumandKidneyDiseasehandout
Limitfluidconsumptionto~4cups/32fluidouncesperday(includingfoods
thatareliquidatroomtemperature)
Useicechipsandsugarfreecandytomanagethirst
Spreadsmalleramountsoffluidsthroughouttheday(~1cup4x/day)
Consumefrozenmealswithlessthan600mg/sodiumatdinner

NextAppointment:

ClinicPhone:(206)8344100

Time

Food

Amount

9:00 am
Breakfast

Eggs scrambled with...

Unsalted butter
Sweet bell peppers, chopped
Onion, chopped
Apple, small
Black coffee
Half and Half
TUMS supplement

2 ea
1 tbsp
cup
cup
1 ea
6 fl oz
1 tbsp

10:00 AM
Snack

Strawberries, fresh or frozen

Bagel plain, unenriched, 3
Cream cheese

cup
1 each
3 tbsp

1:00 PM
Lunch

Tuna salad sandwich

Low sodium bread
Low sodium canned tuna, packed in water
Olive oil
Celery, diced
Lettuce, leaf
Carrots, steamed from frozen, drained
Water
TUMS supplement

2 slices
3 ounces
1 tbsp
cup
2 each
cup
8 fl oz

4 PM
Snack

Apple sauce
Decaf iced tea

cup
6 fl oz

8:00 PM
Dinner

Salisbury steak
Gravy
White Rice with...
Unsalted butter
Green beans, cooked from frozen, drained
Dinner roll, 2.5 inches
Water
TUMS supplement

3 ounces
cup
1 cup
2 tbsp
1.5 cup
1 each
6 fl oz

10:00 PM
Snack

Cherry Pie

1 slice

Therapeutic Diet Explanation

For HDs theapeutic diet, I focused on increasing calories and protein, without going over the recommended limits for
potassium, sodium, phosphorous and fluids as outlined in his nutrition prescription. Although he currently doesnt
wake up early enough to eat breakfast, he might have more energy once he is feeling better and his electrolyte levels
are better balanced. Breakfast is a protein and nutrient rich meal that isnt too time intensive to make with small
portions of vegetables. If energy levels continue to be a concern, a frittata type dish could be prepared by his
daughter, refrigerated, and portioned out as necessary. Eggs are also very affordable.
Tuna salad is a high protein, low cost, low energy lunch meal. As his daughter sometimes prepares food for him, I
created a dinner that is a homemade version of his frozen dinner, with Salisbury steak, white rice, and green beans.
This meal is protein rich, comforting, and calorically dense. The gravy will make the steak easier to chew, especially if
it is cut up into small pieces. The white rice is cheap, can be bought pre-cooked, and has less potassium than the
mashed potatoes in the frozen meal.
Most of the packaged items such as bread, butter, and tuna are low sodium varieties in order to help HD manage his
thirst and fluid intake. I spread his fluids regularly throughout the day within his 960 mL limit so that he wouldnt feel
deprived. The food processor report looks high, but according to Krause, the 3 cups plus urine output is not inclusive
of water within solid foods, which makes up for insensible water loss. According to Krause, ~500 mL of fluid is an
appropriate amount to receive through solid foods, which results in a total of 1500 mL for the day.
The majority of meals meals are relatively soft and easy to chew because his dentures appear to be ill-fitting at this
time. To help manage his blood sugar, I spread out his carbohydrates throughout the day and focused on a mix of
whole grains and refined grains in order to not overdo it on phosphorus.
Natural Medicine Therapy

Patients underdoing hemodialysis often have widespread systemic inflammation, putting them at particular risk for

cardiovascular disease. L-carnitine is important for the beta-oxidation and intermitochondrial transfer of long chain
fatty acids, but is often low in patients with ESRD because of low production levels in kidney and liver and losses
during dialysis. L-carnitine is thought to suppress inflammatory cytokines that may contribute to the inflammatory
process. Levels of C-reactive protein can specifically be used to measure systemic inflammation and is reflective of
other inflammatory compounds being released. A 2006 study by Duranay, Akay, Yilmaz, et al showed that IV
L-carnitine supplementation at a dose of 20 mg/kg led to a significant reduction in CRP levels, indication a reduction in
inflammation. Albumin and transferrin are negative acute phase proteins that are suppressed by inflammation.
Researchers saw that administration of L-carnitine also led to increases in albumin and transferrin, an ideal outcome
for ESRD patients. ESRD patients are at particular risk for hypoalbuminemia which can alter tissue recovery and
repair; transferrin transports iron within the body and decreases can contribute to anemia of chronic disease. Its
important to note that this study was conducted with IV L-carnitine and that other studies on both oral and IV
L-carnitine have been mixed in regards to patients with ESRD. More research needs to be done to assess effectiveness
of this alternative treatment.
Duranay M, Akay H, Yilmaz FM, Senes M, Tekeli N, Yucel D. Effects of L-carnitine infusions on inflammatory and
nutritional markers in hemodialysis patients.
Neprhol Dial Transplant.
2006; 21: 3211-3214.