Nutrition First Office Call

Pt Initials: HD

Appointment length:

60 minutes

ASSESSMENT
Client History
Reason for visit: Referral from nephrologist to implement renal diet. Joined c daughter
Personal hx: 70 yo German American male, quit smoking 5 yrs ago.
Medical hx: Dx c T2DM 10 years ago, but Dr reports pt may have had T2DM several years prior
to dx as well as ESRD. Undergoes Hemodialysis 3x/wk. Has muscle pain, fatigue and low
appetite.
Family Med hx: Not assessed.
Social hx: Lives alone but has an adult daughter living a few miles away.
Food and Nutrition-Related History
Food and Beverage Intake and/or Nutrition Intake Analysis Results: Diet analysis shows
total caloric intake being 1,972 kcal (88% of the recommended caloric amount based on ESRD
caloric need), 73 g of protein (88% of the recommended protein amount for optimal ESRD
health), 5.2 g of K (173% of the recommended K amount for optimal ESRD health), 4,618 mg of
Na (231% of the recommended Na amount for optimal ESRD health) and 1,500 mL of fluid (150%
of the recommended fluid amount for optimal ESRD health). Pt consumes about 4-5 svg of dairy,
greater than the recommended 1 svg of dairy/d for PO4. 24-hour recalls states:
(B): 1c coffee with half and half.
(S): OJ and 2 slices toast with butter.
(L): 2c canned tomato soup, saltine crackers with sliced cheddar cheese and 2% milk.
(D): Salisbury Steak Hungry Man TV dinner with iced tea.
(S): Chocolate chip ice cream.
No consumption of ETOH.
Food and Nutrition History: Pt has taken a class on renal diet, but has trouble remembering
what was learned.
Knowledge/Beliefs/Attitudes/Behaviors: Often eats canned or frozen meals d/t ease of
preparation and preference. Daughter describes pt as set in way.
Food Access and Preparation: Mostly homebound, daughter does most of the grocery
shopping. Pt is set on a fixed income for groceries. Too fatigued to cook, but will heat meals.
Food allergies/Intolerances: NKFA
Physical Activity: Low
Medications and Dietary Supplements: Atenolol, Erythropoeitin, Miralax, Sertraline, Ferrlecit,
Insulin, Nephrocaps, Zemplar, Phosphate Binders (Tums).
Anthropometric Measurements
Height (in/cm): 70 in/177.8 cm
Weight (lb/kg): 153 lbs/ 69.4 kg (dry wt)
BMI: 22.0 (Normal)
Weight hx: 10% wt loss over past year: 1 year ago: 170 lbs, 3 months ago: 159 lbs. Wt before
last dialysis session: 165 lbs, wt after last dialysis session: 160 lbs.
Other measurements: None
Ideal/reference weight: 166 lbs (149lbs 183 lbs)
103%
Usual weight:
170 lbs
% Wt change:
-11%
concern
Desired weight: None
Biochemical Data, Medical Tests and Procedures

%ideal/reference weight: 84%usual weight: 90%

Weight change classification: Of

Pertinent labs/tests/procedures: BUN 20 mg/dL (WNL); FBS 140 mg/dL (High); HbA1C 7.2%
(WNL); Albumin 3.0 g/dL (WNL); K+ 6.4 mEq/L (High); Na+ 126 mEq/L (Low); PO4 7.2 mg/dL
(High); Serum Calcium 8.1 mg/dL (WNL); HCT 36% (Low); HGB 12.2 g/dL (Low); Ferritin 21 ng/mL
(Low); TIBC 455 mcg/dL (High); Transferrin 366 mg/dL (WNL); Triglycerides 244 mg/dL (High);
Total Cholesterol 190 mg/dL (WNL); Urine Output 240 mL (Low).
Nutrition Focused Physical Exam Findings
GI Function: Chronic constipation, BM every 2-3 days but doesnt bother pt much.
Sleep hx: Sleeping during dialysis, but not well at night, possibly due to muscle cramps.
Energy: Low
Stress: Not assessed
Blood pressure: 143/92 mmHg (Stage 1 HTN)
Overall clinical observation: Swollen ankles, dentures fit loosely, slow movement, appears
very tired, nods off a few times during the appointment.

DIAGNOSIS
Problem: Excessive Mineral Intake (Potassium, NI-5.10.2.5)
Etiology: food related knowledge deficit d/t high intake of canned soups and frozen, convenient
foods as well as not understanding how to implement renal diet and having a high preference for
potassium rich foods
Signs and Symptoms: serum potassium being high at 6.4 mEq/L (3.5-5.5 mEq/L reference level
for dialysis pt) and diet intake of 5,158 mg (173% the recommended amount for someone on
dialysis).
Problem: Excessive Fluid Intake (NI-3.2)
Etiology: lack of understanding concerning how to restrict fluids in ESRD
Signs and Symptoms: 1,500 mL fluid intake (150% the recommended amount for someone on
dialysis), low serum sodium (126 mEq/L) and edema of the ankles.

INTERVENTION
Nutrition Prescription
REE/ Kcals: ESRD to prevent wasting: 35 x 69.4 and 40 x 69.4 = 2,229 kcal 2,776 kcal
Protein (g/kg): ESRD to prevent wasting: 69.4 x 1.2 = 83 g
Fluids (ml/kg): 750 mL + urine output of 250 mL = 1,000 mL/d
Other: K kept at 2-3 g; PO4 limited to 1 svg dairy food/d, limit beans, nuts, bran (limit to 1,200
mg/d); Na kept between 1500-2000 mg/d.
Intervention 1: Food and/or Nutrient Delivery Meals and Snacks Decrease Potassium Diet
(ND-1.2.11.5.2): Discussed with pt and daughter the importance of managing potassium and how
too much can cause serious damage. Gave pt and pts daughter a Bastyr Clinic handout of
Potassium and Kidney Disease. Emphasized the amount of servings in each, low, medium and
high groups of potassium the pt should have. Discussed how soaking foods high in potassium
(such as potatoes) can help decrease the potassium amount. Gave pt and pts daughter a Bastyr
Clinic handout of Nutrition Care for the Kidneys. Mentioned to pt to keep this handout and the
potassium foods on the fridge. Asked pt at f/u to provide a 3-day food diary, showing the
incorporation of 1 serving of high-potassium foods on the fridge, 2 servings of mediumpotassium foods and 2-3 servings of low potassium foods.
Intervention 2: Nutrition Education Content Nutrition Relationship to Health/Disease (E-1.4):
Discussed with pt and pts daughter the importance of fluid balance and how Na and fluids
coincide with one-another. Educated pt and pts daughter to keep fluids at 4 c/d (pertaining only
to fluids liquid at room temperature). Gave pt and pts daughter a handout of Davitas Tips for
Managing Thirst for pts on dialysis and mentioned that the most effective way to reduce thirst

and fluid intake is through Na reduction. Asked pt at f/u to provide a diary on fluid intake taken
5/7 days/week.

MONITORING /EVALUATION
Professional goal#1: To reduce risk of cardiac arrest in ESRD, at f/u pt will present a 3-day food
log that shows the incorporation of 1 serving high-potassium foods, 2 servings mediumpotassium foods and 2-3 servings of low-potassium foods.
Professional goal#2: To decrease risk of heart failure in ESRD, pt will present a 5/7 day fluid
diary, adhering to 4 c/d.
Follow up: Assess K and fluid balance, Na, PO4, kcal, protein, COC to address
loosely fitted dentures, address distaste/forgetfulness of phosphate binders, Ca, Lipids, Fe, WaterSoluble Vitamins, Vit D
Handouts provided: Bastyr Clinic Documents Potassium, Kidney Disease and Nutrition Care for
the Kidneys, Davitas Tips for Managing Thirst During Dialysis.
Clinician signature: ____________________________________________________