Andrew Crotty

9/21/16

ADIME
A : (Assessment) (5pts):

Age: 52 Gender: Male Dx: AFIB

PMHx: Anemia, CKD stage 5, DM2, Heart murmur, HTN, Hyperthyroidism, Inner ear
infection, Metabolic acidosis, ESRD,
Therapies: Peritoneal catheter placed, Peritoneal Dialysis
Ht: 55 or 1.65 m Wt: 75.3 kg IBW: 59.5kg %IBW: 127
UBW: 76.2 kg %UBW: 99%
BMI: 27.7 Wt changes while in hospital: 1% decrease in last four days

Nutl Requirements: (5pts)

kcal: Mifflin St Jeor X 1.2 = 1839 cal
25 kcal/kg = 1883 kcal/d (1373 cal remaining c dialysis)
Protein 1.5gm/kg = 113g pro/d
***You and I agreed this is as low as we could go despite phosphorus restriction
Fluid = 25cc/kg = 1883 cc/day

Continuous ambulatory peritoneal dialysis (CAPD): [(Dextrose % X L) X 3.4] X 60% =

kcal

[(2000ml bag x 2.5% dextrose)= 50g Carb x 3.4cal/g= 170cal x 0.6 (absorbed) = 102
calories x 5 (Daily exchanges)= 510 carb calories from dialysate per day

Calories from Carbohydrates (50%): 920(230g carb) 510cal(dialysis)=410cal 103g carb

Calories from Fat (25%): 460 (50g fat)
Calories from Protein (25%): 460 (115g pro)

Other nutrients as deemed necessary:

*justifications in addendum*
K, Phos, Na
Supplementation of:
Folate 1g/day
Vitamin C
B complex
Calcium
Vitamin D 1,25 (OH)2D3
Intravenous Iron
Diet Order: (Current and others in chronological order) (5pts):

Renal CCHO (CURRENT ADMISSION)

The Renal CCHO order isnt appropriate because, the restricted protein intake associated
with a Renal diet isnt necessary in a patient on peritoneal dialysis. This patient could
benefit from a more liberalized protein intake. However, the sodium restriction
component of the renal diet is still necessary. This would mean a change from a Renal
CCHO diet to a CCHO 2G NA diet could be beneficial. I also believe other restrictions
(K+ and PO4) and supplementations (Ca, B complex, Vit. D and C, Fe, and folate) should
be in place. These are outlined in the intervention section. The potassium restriction
typical with peritoneal dialysis can be on the upper end towards 4G due to the normal lab
value along with the use of Lasix.

Labs: (5pts) Explain relevant lab values both normal and

abnormal

I&O: -1475 (24hr) BP: 139/75 98.5F

HC BU CR WB HG HC PL
Na K Cl 03 N E GLU C B T T
(232
-
135 4. 97 5.6 283) 14.0 10. 29
L 1 L 22L 72H H H H 8L 5L 3
A1c: 12.2 (high since 2007)

Sodium is found to be lower than its ideal range of 136 to 144 mEq/L. This is
likely due to the edema present in this patient.
Potassium is normal, if it were high than it would need to be restricted in the diet
because the impaired kidney cant properly regulate electrolytes.
Chloride is lower than its ideal range of 98 to 107 mEq/L. This is likely due to the
ions dilution occurring with edema.
Bicarbonate is lower than its ideal range of 23 to 29 mmol/L. This is likely due to
renal failure.
BUN is higher than its normal range of 8 to 23 mg/dL. This is likely due to the
decreased ability of the kidney to clear nitrogenous wastes during kidney
Creatinine is higher than its normal range of 0.4 to 1.2 mg/dl. This is likely due to
the decreased ability of the kidney to clear nitrogenous wastes during kidney
disease.
Glucose is high above of its normal range 70-99 mg/dL. This is an indicator of
poorly regulated blood glucose in the diabetic patient. This could also be elevated
due to the use of Colace.
Hemoglobin is lower than its ideal range of 12.1 to 15.6 g/dL. This can be due to
the anemia and hyperparathyroidism present with this patient.
 Hemoglobin A1C is higher than its normal range of 4 to 6%. This indicates
diabetes is being poorly controlled.
White blood cells are higher than their usual range of 3.2 to 10.6. This may be due
to the trauma associated with the recent placing of the peritoneal catheter.
Hematocrit is lower than its usual range of 41 to 51%. This is likely due to the
anemia of chronic kidney disease present in this patient.
I & O is negative indicating fluid retention is declining
BP is high likely contributed to by the retention of fluid leading to
its increased presence in vascular spaces.

Meds: (5pts)

Clonidine
Antihypertensive
Taken c low Na diet
Avoid licorice and alcohol, insure adequate fluids

Colace
Stool softener
Mix c 8oz milk or juice
Take c high fiber and 1500-2000ml fluid diet
Make raise [glu] and [K]

Carvedol
Antihypertensive
Take c food
May be taken c Na and Cal restrictions
Avoid licorice

Normal Saline (NaCl 0.9% 1000ml)

Replenishes fluids and electrolytes
Could contribute to retained fluid

Diovan
Antihypertensive
Take c food
May be taken c Na and Cal restrictions
Avoid licorice, caution c citrus

Valsartan
Antihypertensive
Take c food
May be taken c Na and Cal restrictions
 Avoid licorice, caution c citrus

Heparin
Anticoagulation
Constipation
Caution c DM & ESRD- Hyperkalemia

Humalog
Insulin, Hypoglycemic
Taken c CCHO diet
Caution c decreased renal function or hyperthyroidism

Lantus
Insulin, Hypoglycemic
Taken c CCHO diet
Caution c decreased renal function or hyperthyroidism

Lasix
Diuretic (K-depleting), Antihypertensive
^ K and ^ Mg in diet
Reduction of Cal or Na may be recommended
Avoid natural licorice

Amlodipine
Anithypertensive
Reduction of Cal or Na may be recommended
May cause hypotension or edema

Famotidine
Antisecretory
Take c water
Bland diet may be recommended
Take Mg or Fe supplement at least 2 hours before or after
May reduce Fe & B12 absorption

Nutrition Focused Physical Findings: (obesity, cachexia, decubitus, mental status) (5pts)

Upon examination F.H. appeared to be retaining fluids, edema (+1) was present in
his right arm and hand. This wasnt typical for him. His surgical wound on his abdomen
appeared to be intact along with the peritoneal catheter, which had just been placed. His
skin was of good turgor. There wasnt any signs of depletion in either somatic muscle
mass or subcutaneous fat stores. He was alert and oriented upon my arrival and proved to
be fairly talkative.
Pertinent Social Hx: (5pts)

F.H. is a well appearing 52-year-old Caucasian male. His wife and parents are all
deceased. He lives with his sister whom does his shopping and cooking. He is single and
Catholic. He denies any difficulty in regards to food preparation or consumption. He
denies alcohol consumption and has no past history of illicit drug use. Both Heart and
Renal Disease run in his family.
Nutrition History, Diet PTA (5pts)

Prior to admission F.H. reported to have a fair diet. He reported compliance with a
sodium restriction related to his renal diet and cardiovascular disease. When asked about
controlling carbohydrates related to his diabetes he claimed he tried to limit sweets, but
often failed. He also claimed carbohydrate consumption was highly inconsistent as only
one meal was eaten per day around lunchtime. This large meal typically consisted of
various sandwiches made by his sister including meats. They meats werent usually cold
cuts, rather, they were various cuts of meat cooked on a pan. He is most likely to request
a chicken sandwich, as chicken is his favorite protein source. He claimed other meals
were skipped due to lack of appetite. However, it became apparent sweets were
consumed at night. Snack items included candy, cookies, and other sweets. It seemed F.H.
lacked any knowledge towards the application of a consistent carbohydrate diet and its
benefits in regards to controlling blood glucose levels.

Summary of Current Intake (5pts)

F.H. claimed to have regained his appetite since his recent surgery. He reports to
be eating his normal one meal a day along with typical snacks. He enjoys the food
options and has no complaints about the meals. He is following his sodium restriction
however is completely unaware of his consistent carbohydrate diet.

D (Diagnosis) (5pts) PES

Inconsistent carbohydrate intake related to food and nutrition related knowledge deficit as
evidenced by Hbg A1c of 12.2H and patients report of consuming only one meal per day.

I (Intervention) (15 pts) Stems from Nutritional Diagnosis and Etiology and must
determine patient-focused expected outcomes for each nutrition diagnosis
Organized into 4 categories: (Include only categories that pertain to your patient)

Food and/or Nutrient Delivery (meals, snacks, enteral and/or parenteral feeding;
supplements as in commercial, food/drink based, or vitamin/mineral)

*These are recommendations, NOT orders

CCHO followed by consumption of three full meals >75%
Reduced tendency to snack on sweets
2g Na restriction
4g K restriction
 Nephrocap
o 1200mg Phosphate restriction
o Folate 1g/day supplementation
o Vitamin C supplementation
o B complex supplementation
o Calcium supplementation
Vitamin D 1,25 (OH)2D3 supplementation
Intravenous Iron supplementation (with use of synthetic EPO)
Nutrition Education
Purpose of restrictions
Dietary modifications to abide by restrictions
CCHO explanation
Importance of supplementation for nutritional wellbeing

Coordination of care
Recommend restrictions to MD
Discuss possible supplementation with MD
Nursing staff to monitor BG and Wt.
Have nursing staff monitor compliance to supplementations (if becomes
applicable), diet, and restrictions

M/E Monitoring and Evaluation (10pts) Nutrition care indicators that will reflect a
change in nutrition care provided

Organized into 4 categories: (Include only categories that pertain to your patient)

Food/Nutrition Related Outcomes (Food intake, supplement use)

Frequent inquiry to the patient and mealtime observation could give insight towards
supplement intake (if applicable) along with compliance towards dietary modification.

Anthropometric Measurement Outcomes (Ht, Wt, BMI)

The weight of F.H. should be monitored daily until it remains fairly consistent, indicating
the absence of fluid retention.

Biochemical Data, Medical Tests, and Procedure Outcomes (glucose, electrolytes,

gastric emptying)

Ferritin- monitored to hopefully keep over 100ng/ml, if below intravenous Fe

supplementation may be necessary
Fe- monitored to keep from falling below normal limits while anemia resolves
RBC- monitored for increase towards normal limits as anemia resolves
Hct- monitored for increase towards 41 to 51% as anemia resolves
Potassium- monitor to avoid hyperkalemia despite decreased renal function
Creatinine- monitor for ability of CAPD to remove nitrogenous wastes from body
BUN - monitor for ability of CAPD to remove nitrogenous wastes from body
Glucose- monitor for <200mg/dm with better regulation of DM
A1C- monitor for lowering towards 4 to 6% with increased regulation of [Glu]
Phosphate- monitor for staying within normal limits as a result of phosphate restriction
despite low ability of PD to clear phosphate
Ca- To remain within normal limits despite impaired absorption typical with ESRD
PTH- Monitor for lowering towards normal limits as secondary hyperparathyroidism due
to Renal Osteodystrophy is resolved through Ca and Vitamin D supplementation
Na- Monitored to rise to 136mEq/L as edema resolves due to compliance with Na
restriction
I & os- Monitor for losses as edema is resolved until balance is reached

Nutrition-Focused Physical Findings Outcomes (physical appearance, muscle/fat

wasting, swallow function, appetite)

The patients edema should subside; this occurrence could be

monitored subjectively upon evaluation by nursing.
The patients appetite should be more consistent throughout the day
while having three full meals versus past diet of one large meal per
day. Nursing staff could also monitor this occurrence.

Nutrition Education Outcomes

Pt. able to name 3 high sodium food items.

Pt. able to name 3 high potassium food items.
Pt. able to name 3 high phosphate food items.
Pt. able to state 2 steps that can be taken to follow CCHO diet
ADDENDUM TO ADIME
1. For current Dx (5pts) MNT

End stage renal disease that is managed with Peritoneal Dialysis (PD) involves the
infusion of carbohydrates into the body due to the high concentration of dextrose present
in the dialysate. The amount of calories entering the body can be calculated using the
formula: Continuous ambulatory peritoneal dialysis (CAPD): [(Dextrose % X L) X 3.4]
X 60% = kcal. Dietary intake must be modified to account for this caloric intake.
However, in this diabetic patient the high serum levels of glucose may cause water and
potassium to be pulled out of cells and result in hypokalemia. Dialysis can drain the body
of protein. Those on PD should consume 1.2 to 1.5g/kg of protein. High protein
consumption is no longer a concern for the renal patient because dialysis will remove
nitrogenous wastes produced by protein metabolism. Caloric intake of 25 calories per kg
of body weight is sufficient for the nutritionally sound PD patient. Sodium is often
restricted to 2g. This is because, excessive sodium can result in fluid retention, edema,
and hypertension. Potassium may need to be restricted based on close monitoring of
serum levels. This is because electrolytes arent properly regulated when kidney function
is impaired. A typical potassium restriction for a patient on CAPD is 4g. Phosphate isnt
easily cleared by dialysis, therefore its intake must be restricted to about 1200mg/d. This
is difficult due to its presence in protein, which is plentiful in this diet. In ESRD the
kidney has less ability to convert vitamin D into its active form. Therefore, calcium isnt
properly absorbed. This can lead to over-secretion of PTH in order increase calcium
reabsorption to restore serum levels. This is referred to as Renal Osteodystrophy and can
lead to secondary Hyperparathyroidism. To avoid these complications active vitamin D
and calcium are supplemented. Anemia of chronic renal disease is commonly caused by
the kidneys loss of ability to produce EPO, which stimulates red blood cell (RBC)
production in bone marrow. This form of anemia is often treated by use of a synthetic
EPO that results in such a drastic increase in RBC production that iron needs cant be met
orally. Intravenous iron is used periodically when serum ferritin (stored form of iron)
levels fall below 100ng/ml. Water soluble vitamins are often lost during dialysis. Folate is
often supplemented at 1g/day. Vitamin C is also supplemented along with a vitamin B
complex.1

2. Pertinent Drug/Nutrient Interaction Information if NOT

addressed in note (5pts) Addressed in ADIME

This example meal plan was made to meet a prescribed diet of

Renal CCHO 1800 calories 2g Na for a patient not on PD.
Realzing patient is on PD, total intake would decrease
specifically of carbohydrate containing foods, and protein
supplement Nepro may be utilized, is designed for renal pts
and is carbohydrate steady.

3. Menu Plan or (10 pts) CCHO 2G Na (4G K, 1.2G PO4)

Breakfast
Calorie Carbs Protein
Food Amount s (g) Fat (g) (g) Na (mg)
eggs 2 154 2 10 12 62
blueberri
es 1/2 cup 39 10 0 1 1
greek
yogurt 1 cup 137 19 0 14 189
Bran
cereal 1/2 cup 48 8 0 4 4
banana 1 90 23 0 1 1
meal
total 468 62 10 32 257

Lunch
Calorie Carbs Protein
Food Amount s (g) Fat (g) (g) Na (mg)
wheat
bread 2 slices 132 24 2 6 260
chicken 3oz 279 15 15 21 384
sliced
tomato 1/2 cup 79 3 0 1 33
almonds 1oz 162 6 14 6 0
greek
yogurt 1cup 137 19 0 14 189
meal
total 789 67 31 50 866

1 Krause
Dinner
Calorie Carbs Protein
Food Amount s (g) Fat (g) (g) Na (mg)
chicken 3oz 279 15 15 21 384
wheat
bread 2 slices 132 24 2 6 260
sliced
tomato 1/2 cup 79 3 0 1 33
carrots 1 cup 54 12 0 2 90
apple 1 60 15 0 0 0
meal
total 604 69 17 29 767

Calorie Carbs Protein

s (g) Fat (g) (g) Na (mg)
daily
total 1861 198 58 111 1890

*I was able to follow all components of proposed diet plan besides the
phosphate restriction. It isnt feasible to have such a low phosphorus
intake when protein needs are so high. However, I was able to keep
phosphorus relatively low in relation to the amount of protein
consumed.

PROTEIN & AMINO

ACIDS TOTAL %DV
Protein 111.1 g 196

FATS & FATTY ACIDS TOTAL %DV

Total Fat 64.4 g 99
Saturated Fat ~12.4 g ~62

VITAMINS TOTAL %DV

Vitamin A 3204 IU 64
Vitamin C 51.5 mg 86
Vitamin D ~ IU ~
Vitamin E (Alpha
Tocopherol) ~11.0 mg ~55
Vitamin K ~27.4 mcg ~34
Thiamin 1.6 mg 108
Riboflavin 2.8 mg 165
Niacin 19.1 mg 96
 Vitamin B6 ~1.4 mg ~68
Folate ~369 mcg ~92
Folic Acid ~20.0 mcg
Dietary Folate
Equivalents ~383 mcg
Vitamin B12 4.7 mcg 78

CALORIE INFORMATION TOTAL %DV

(7457
Calories 1833 kJ) 89
From Carbohydrate 806
From Fat 571
From Protein 456
From Alcohol ~0.0

CARBOHYDRATES TOTAL %DV

Total Carbohydrate 210 g 70

MINERALS TOTAL %DV

Calcium 1341 mg 134
Iron 13.1 mg 73
Magnesium 465 mg 116
Phosphorus 2038 mg 204
Potassium 3304 mg 94
Sodium 1875 mg 78

References:

Krause

Mahan, L. Kathleen., Sylvia Escott-Stump, Janice L Raymond, and Marie V Krause. Krause's Food & the
Nutrition Care Process. 13th ed. St. Louis, Mo.: Elsevier/Saunders, 2012.

FMI

Pronsky, Zaneta M., and Jeanne P. Crowe. Food Medication Interactions. Birchrunville, Penn.: Food-
Medication Interactions, 2010. Print.

Nutrition Care Manual

Nutrientdata.com