Adime 3
Adime 3
Adime 3
ADIME #3
A : Assessment:
Age: 45 Gender: F Admit Date: 3/27/19 Date Seen: 3/28/19 Patient Initials: M.G.
Admitting Dx: Patient M.G. is a 45 year old female who was readmitted to UCONN Health Center
on March 27, 2019 for abnormal potassium levels. Patient M.G. reported was getting blood work
done during her Peritoneal Dialysis when her potassium levels were found high. M.G. She denies
any symptoms such as headache, chest pain, shortness of breath and states being in a regular state
of health when this occurred. Upon admission high blood pressure in addition to high potassium
levels (7 mol/L) were identified. Primary medical diagnoses for hospitalization were hyperkalemia
and hypertension.
Hyperkalemia occurs when potassium levels in the blood are higher than normal, levels above
6.0 mmol/L can be dangerous. High K+ can result from kidney disease impairing K+ excretion,
medications (such as potassium-sparing diuretics, gastrointestinal hemorrhage,
rhabdomyolysis, catabolism, or metabolic acidosis. 1
Hypertension (HTN) also known as high blood pressure, occurs when blood pressure levels
exceed 120/80mmhg which can cause damage to organs such as cardiac, peripheral, renal, or
retinopathy organ systems when blood pressure is too high.1
Treatments/Therapies: Upon admission, calcium gluconate, insulin and dextrose, Lasix and repeat
K+ levels. Kayexalate with repeat K+ in 4-5 hours was recommended upon Nephrology consult.
EKG was performed showing no signs of peaked t waves or heart blockers. M.G. is receiving
50mL/hr Dextrose 10% IV infusion continuously. Patient is currently receiving Peritoneal Dialysis
with Peritoneal Dialysis solution (DELFEX) 1.5%.
PMHx: M.G. was last admitted to UCONN Heath Center in January 2019 for an infection in the
peritoneal dialysis catheter exit site and hypertension.
Chronic Kidney Disease (CKD)-Stage 5 also referred to as End-Stage Renal Disease is when
kidney failure occurs resulting in the inability of the kidney to excrete waste products , maintain
fluid and electrolyte balance , and produce certain hormones. This stage requires dialysis,
transplantation or medical management. 1
Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease characterized by
production of autoantibodies directed against nuclear and cytoplasmic antigens affecting
several organs. 1
Hypoglycemia occurs when blood sugar is low (below 70 mg/dl) affecting the brain and
nervous system that can cause sweating, shaking, hunger, headaches, and irritability. 1
Secondary Hyperparathyroidism of renal origin occurs in patients with chronic kidney failure
and arises when the parathyroid glands become enlarged and release an excessive amount of
parathyroid hormone (PTH) resulting in high blood level of PTH. 1
Bell’s Palsy is when the muscles on one side of the face become weak or paralyzed resulting
in it drooping or becoming stiff.
Carley Bedell
UCONN Health Center
Date: 3/28/19
Anemia due to CKD occurs when there is significant damage to kidney function causing a
decrease in production of erythropoirtin (EPO) resulting in fewer red blood cells produced by
the bone marrow.
Calculations:
Ideal Body Weight: Women- 100lbs for first 5ft. Add 5lbs each inch over 5in.
100lbs + 5in (4 in) = 124 lbs Ideal Body Weight
𝐴𝑐𝑡𝑢𝑎𝑙 𝑤𝑒𝑖𝑔ℎ𝑡
Desirable Body Weight: %DBW = ∗ 100
𝐼𝑑𝑒𝑎𝑙 𝑤𝑒𝑖𝑔ℎ𝑡
163
%DBW = 124 ∗ 100 = 132%
No significant weight changes were reported by patient. G.M. reported usual body weight around current
body weight, may fluctuate within 5lb.
Nutrition Requirements:
kcal: Mifflin St Jeor X (AF) X (IF) = (10 X 74 kg) + (6.25 X 162.6 cm) – (5 X 45 y/o) - 161 = 1364 kcal
1700kcal was decided for calorie requirements due to overweight status, energy needs for dialysis
and to increase dietary compliance
Carley Bedell
UCONN Health Center
Date: 3/28/19
Due to severity/progression of chronic kidney disease and high BUN and Creatinine levels, the
lower range of protein- 67g was used
I would use 1400cc fluids considering continuous IV infusion of dextrose and progression of renal
disease
Potassium= 3-4g/day
Phosphorous= 0.8-1.2g/day
Sodium 1.5-4g/day
Diet Order:
Current Order: Renal, Consistent Carb, low K+
Considering M.G. is not diabetic, a consistent carb diet restriction may not be necessary. This may
increase dietary compliance. If blood sugar is consistency irregular after liberalization consider
reintroducing consistent carb restriction.
3/28/2019 Blood Urea 85 mg/dL 10 - 20 HIGH, M.G.’s high BUN level indicates low
Nitrogen (BUN) mg/dL dietary compliance despite treatments and diet.
(89 on 3/27) Showing her renal condition is not under control.
3/28/2019 Sodium (Na) 136 mmol/L 136 – 145 System flagged LOW- On lower range. Patient has
(was 139 mmol/L kidney failure and is on diuretics
3/27)
3/28/2019 Potassium (K) 5.7 mol/L 3.5 – 5.0 HIGH, reason for hospitalization. Nephrology is
(was 5.2 mol/L addressing cause. K+ level was 7mol.L upon
3/27) admission
3/28/2019 White Blood Cell 3.8 k/cmm 5 – 10 LOW, may be related to Hx anemia related to renal
(WBC) k/cmm condition
3/28/2019 Red Blood Cell 4.19 4.7 – 6.1 LOW , hx anemia related to renal condition
(RBC) cells/mcL cells/mcL
3/28/2019 Hemoglobin (Hb) 12.5 g/dL 14 - 18 LOW, hx anemia related to renal condition
g/dL
3/28/2019 Calcium 7.7 mmol/L 8.7-10.5 LOW, damage of kidney from Kidney Failure
mmol/L causes abnormalities to hormones (such as PTH,
Parathyroid hormones) resulting in an imbalance of
calcium and phosphorous levels in the blood. 6
PrednisONE Arthritis, blood Nausea, vomiting, loss of Take this medication by mouth with
(DELTASONE) disorders, breathing appetite, heartburn, trouble food or milk, may make blood sugar
problems, severe sleeping, increased sweating, rise
allergies, skin or acne
diseases, cancer, eye
problems, and
immune system
disorders
Sevelamer Lower high Headache, diarrhea, stomach Take by mouth with meals
Carbonate Phosphorous in Blood upset, nausea, vomiting,
(RENVELA) cough, gas, or constipation.
Physical Assessment:
Patient was alert and oriented but not cooperative with interview. She appeared overweight, her hair was
thin and skin slightly pale. G.M. had all her original teeth and is able to tolerate regular textured food and
consistency. Patient appeared tired, her eyes were slightly droopy. She used a bed pan for urinating.
Carley Bedell
UCONN Health Center
Date: 3/28/19
D (Diagnosis) PES:
Limited Dietary Adherence related to renal, consistent carb and low potassium diet as evidenced by High
BUN level ranging between 85-89, High creatinine of 15 and patients limited ability to provide a dietary
recall
I (Intervention):
Organized into 4 categories:
Food and/or Nutrient Liberalizing the patients diet from renal, consistent-carb, low potassium to
Delivery renal, low potassium will help improve G.M.’s dietary adherence.
Developing routine meals and snacks with smaller portions. Patient will be
recommended to take a calcium with vitamin D to improve calcium levels
and Iron with vitamin C supplement to improve iron. Light walking (15-20
minutes) daily will also be encouraged. Consult with Dr. about Heparin
(PORCINE) Injection and assess whether drug may be contributing to
elevated blood pressure.
Nutrition Education Patient will be educated about healthy modifications to her favorite meals
and how to incorporate them while still adhering to her diet restrictions
such a using chickpea pasta like Banza and using a light Carbonara sauce
using light cream and low sodium chicken stock. Education on portion sizes
will be given and how snacks between meals can improve satiety and help
decrease portion sizes. Ways to incorporate more F/V was discussed.
Nutrition Counseling Address the causes for the patient not adhering to her diet and help patient
come up with strategies to overcome them. Help motivate patient to follow
her diet, provide support.
Coordination of Coordinate with nephrology department, doctor (at hospital), nurse (at
Nutrition Care hospital) and coordinate with G.M’s outpatient nephrology doctor/dietitian
Carley Bedell
UCONN Health Center
Date: 3/28/19
Food/Nutrition Related Pt will consume at least 75% of her meals and supplements by F/U
Outcomes Pt will adhere to renal diet by F/U
Pt will report smaller portions and healthier diet modifications by F/U
Pt will walk 15-30 minutes 2-3 days/week by F/U and gradually increase to 3-4
days/week over the next 6 months
Monitor PO intake and supplement intake
Anthropometric Pt will have a gradual 5% weight loss over the next 6 months
Measurement Outcomes Monitor weight
Biochemical Data, Medical Monitor serum calcium, potassium, H/H, BUN, Creatinine, glucose, and
Tests, and Procedure electrolytes
Monitor blood pressure values
Nutrition-Focused Physical Pt appetite will decrease due to higher diet satiation by F/U
Findings Outcomes Pt demeanor will improve by F/U due to increase in exercise
Nutrition Education Pt will be able to state 3 ways to modify dishes to fit her diet and keep satiated
Outcomes Pt will display knowledge about decreasing portion sizes by incorporating more
snacks.
Meal Plan:
1. For current Dx explain- Foods Allowed, Foods Not Allowed, Diet Instruction Materials if appropriate.
Describe in your own words the rationale for diet restrictions/modifications
Foods Allowed NPO
Foods Not Allowed N/A
Diet Instruction If diarrhea continues evaluate EN composition and assess other contributing factors
Materials if appropriate such as medication.
**G.M’s favorite dishes (pizza & Carbonara) were provided with healthy modifications and appropriate
portions to ensure adherence and patient satisfaction. More fruits and vegetables were offered at meals.
For breakfast an orange was given instead of orange juice. Diet was 100kcal below calculated amount of
1700kcal/day which may further be beneficial for weight loss. The protein was below the amount calculated
of 67g protein which actually may be more benficial, could increase protein # given if concern as rises.
Potassium, sodium and phosphorous were all below 2g.
References:
1. Mahan, L. Kathleen., Sylvia Escott-Stump, Janice L. Raymond, and Marie V. Krause. Krause's
Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier/Saunders, 2012.
2. “Bell's Palsy - What Is Bell's Palsy? What Causes It?” WebMD, WebMD,
www.webmd.com/brain/understanding-bells-palsy-basics. Accessed March 31, 2019.
3. Academy of Nutrition and Dietetics. (2013). Nutrition Care Manual. Retrieved from Academy of
Nutrition and Dietetics Web Site: http://nutritioncaremanual.org/auth.cfm?p=%2Find
4. Medications and Drugs. (2005-2019). WebMD. https://www.webmd.org/drugs
5. Metabolic Acidosis. National Kidney Foundation.
https://www.kidney.org/atoz/content/metabolic-acidosis. Accessed April 1, 2019
Carley Bedell
UCONN Health Center
Date: 3/28/19
6. Mineral & Bone Disorder In Chronic Kidney Disease. National Institute of Diabetes and
Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/kidney-
disease/mineral-bone-disorder. Accessed April 1, 2019.