University of Maryland

University of MarylandCollege ParkDietetic Internship2014-2015 MINI CASE STUDYRory Costigan

Nutrition Assessment: Admitting Diagnosis: CKD, abdominal ache/pain and watery stools over past 3 weeksFinal Medical Diagnosis Inadequate fluid intake

Age: 60Gender: MaleWeight: 76.4kg (168lbs)Height:175cm (59)BMI: 24.8 (normal, healthy weight)

PMH:Chronic Kidney disease Stage 3Renal TransplantHypertensionHyperlipidemiaCoronary Artery DiseaseDiabetes Mellitus IIGERDHepatitis C

Symptoms:Lower abdominal pain with watery diarrhea over the past 3 weeks. 7/10 on pain scale and increases when he has a bowel movement and relieves with emptying bowl.Diarrhea has no blood or mucus and denies food borne illness or consuming different types of food.

Diet History:Per Patient, good appetite and usually consumes all the food on his plate. Patient has been previously counseled by a dietitian about keeping blood sugars down, therefore patient tries to follow diabetic diet and tries to keep his weight around 160 pounds. Patient eats 1-3 meals a day when at home. Labs:Creatinine- 2.1mg/dl H (0.7-1.5)Glucose- 90mg/dl (70-121) Urea Nitrogen- 25mg/dl H (6-23) Sodium- 137mmol/L (135-147)Calcium- 8.9mg/dl (8.9-10.5)Phosphorous- 2.4mg/dl L (2.5-4.5)Cholesterol- 181mg/dl (170-200)Albumin- 3.0g/dl L (3.7-5.0)WBC- 2.0 K/cmm L (3.2-9.5)HGB- 12.0g/dl L (13.2-17.3)HCT- 35.1% L (38.6-50.1)HGB A1c- 6.1% (4.3-6.1)

Medications: Amlodipine, Clopidogrel, Insulin Sliding Scale, Metoprolol, Omeprazole, Rosuvastatin

Current Diet:No Condensed Sweets, Renal Diet 1

Nutrition Diagnosis utilize PES Statements

NI 3.2 Inadequate fluid intake related to excessive fluid loss through diarrhea x 3 weeks as evidence by patient statements.

Nutrition Intervention Nutrition prescription, Interventions with goals

Nutrition Prescription:

No concentrated sweets and Renal Diet 1

Calories- 1,909-2,290 Kcal/day(25-30 Kcal/Kg)Protein- 61 g/day(0.8g/kg)Fluid- 1909ml/day(1ml/kcal)Intervention with goals:

Diet: Continue on no concentrated sweets and Renal Diet 1Food and Nutrient delivery: Turkey sandwich for night time snackPatient Educations: Patient has been counseled by a dietitian in the past about controlling blood sugars and could recall and verbalize information about the importance of keeping blood sugar within normal limits.

Nutrition Monitoring and Evaluation

Indicator1. Energy intake2. Monitor sugar intake3. Weekly weights4. Replete electrolytes

Criteria1. Consumes 75% of tray.2. Patient consumes limited concentrated sweets.3. Monitor lean body mass by recording weights weekly. 4. Replete electrolytes RPN

SourceKcal requirementsProtein requirementsFluid requirements

Facility standards1,909-2,290 Kcal/day(25-30 Kcal/Kg)61 g/day(0.8g/kg)1909ml/day(1ml/kcal)

EALn/a- nothing foundn/a- nothing foundn/a nothing found

Online nutrition care manualCKD stages 1-4 diabetic meal pattern should be estimated around 2,200 calories.For patients with a kidney transplant, 0.8 protein/kg/ day to 1.0 g protein/day should be prescribed. The need for a fluid restriction is determined by medical status, blood pressure control, physical findings (fluid accumulation), and alterations in urine output.

References:

1. Academy of Nutrition and Dietetics. International Dietetics and Nutrition Terminology (IDNT) Reference Manual. Chicago, IL: American Dietetic Associations; 2013

2. Academy of nutrition and Dietetics. Nutrition Care Manual. Accessed November 11, 2014 http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&ncm_toc_id=144973&ncm_heading=Nutrition%20Care&ncm_content_id=90573#LaboratoryandLabValueNorms http://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=336

3. Evidence Analysis Library. Academy of Nutrition and Dietetics. www.adaevidencelibrary.com. Accedded November 11, 2014