ckd in the long term care setting presented by: mujan noroozian, utmb dietetic intern department of...

Department of Nutrition & Metabolism

CKD in the Long Term Care Setting

Presented by:

Mujan Noroozian,

UTMB Dietetic Intern

http://www.cliparthut.com/cartoon-kidney-clipart.html

Objective

At the end of this presentation, you will be able to

• identify the factors that affect the elderly with CKD

• compare the current long term care available for the elderly versus what is necessary for optimal care

• recognize the different health care team members needed to treat elderly CKD patients, in particular, nurses (RN) and dietitians (RD)

Top Eight Leading Causes of Death for Adults >65 years

Rank Cause of Death1 Heart Disease-479,150

2 Malignant neoplasms-391,035

3 Chronic lower respiratory disease-117,098

4 Cerebrovascular disease-109,238

5 Alzheimer’s disease-79,168

6 Diabetes mellitus-48,944

7 Influenza and pneumonia-43,469

8 Nephritis-40,465

Dorner, B., & American Dietetic Association. (2010). Position of the american dietetic association: Individualized nutrition approaches for older adults in health care communities. J Am Diet Assoc, 110(10), 1549-1553. doi:10.1016/j.jada.2010.08.022

Risk Factors of CKD

• Age

• HTN

• Diabetes

• Liver Disease

• Vascular Disease

• Hypovolemia

• Nephrolithiasis

• Infections

• Medications (i.e. NSAIDs)

Beto, J. A., & Bansal, V. K. (2004). Medical nutrition therapy in chronic kidney failure: Integrating clinical practice guidelines. Journal of the American Dietetic Association, 104(3), 404-409. doi:10.1016/j.jada.2003.12.028

Those at Highest Risk

1. Elderly patients in rehabilitation and long term care facilities most often have renal failure, whether it be acute or chronic.

2. Diabetics

3. Those with HTN

4. Minorities

Beto, J. A., & Bansal, V. K. (2004). Medical nutrition therapy in chronic kidney failure: Integrating clinical practice guidelines. Journal of the American Dietetic Association, 104(3), 404-409. doi:10.1016/j.jada.2003.12.028

Factors Affecting the Elderly

Medical/Health Status

• Chronic or acute illnesses

• Sensory changes: taste, smell, appearance, texture

• Oral health

• Medication use



Physical/Functional Status

• Physical limitations

• Balance

• Physical strength /endurance

• Physical activity

http://jennygardiner.net/blog/?tag=aging



Cognition

• Mental status change

• Depression

• Emotional needs

• Nutrition/health beliefs



Environmental

• Living situation

• Economics

• Lifestyle

• Access to food and food preparation

• Socialization

• Religious/cultural beliefs and traditions


Common Nursing Home Problems

• Lack of privacy

• Poor quality of care

• Neglect and abuse

• Infections

• Inexperienced staff

• High turnover in staff members

• Small ratio of staff members to residents

Assisted living and nursing home issues: http://www.cobar.org/repository/Public_Docs/slh/21_Assisted_Living_and_Nursing_Home_Issues.pdf. Accessed July 19, 2015.

Considerations for the Elderly in Long Term Care

Environment

• Is the environment clean, well maintained, relaxed, friendly

• Are there safe, accessible walking paths

• Are there safety devices (fire alarms, sprinklers)

• Are the dining rooms pleasant

Nursing homes (skilled nursing facilities): http://www.merckmanuals.com/home/older-people-s-health-issues/provision-of-care-to-older-people/nursing-homes. Accessed July 20, 2015.


Meals

• Times that meals are served

• Are meals served hot

• Are meals nutritious and do they taste good

• Are snacks available between meals

• Can meals be provided in resident’s room

• Are the dining rooms easily accessible for residents

• Can the nursing home provide special diets and special textures

• Are staff members available and able to help with feeding a resident



Health Care

• Therapy programs (physical, occupational, speech therapy)

• How prescription drugs are ordered and given

• How use of drugs are monitored

• Other health care practitioners (dentists, dietitians, optometrists, social workers, counselors)

• Transportation to and from physician’s office


Dialysis Care Team

1. Nephrologist (MD)

2. Nurse Practitioner (NP) or Physician Assistant (PA)

3. Nephrology Nurse (RN)

4. Renal Dietitian (RD, CSR)

5. Nephrology Social Worker

National Kidney Foundation. (2015). Clinical practice guidelines for chronic kidney disease. www.kidney.org. Accessed July 9, 2015.

http://www.kidney.org/

Dialysis Care Team

6. Patient Care Technician (PCT)

7. Biomedical Technician

8. Vascular Access Surgeon

9. Radiologist

10. Access Coordinator

National Kidney Foundation. (2015). Clinical practice guidelines for chronic kidney disease. www.kidney.org. Accessed July 9, 2015.


Nursing Care Planning

• Monitoring blood pressure

• Monitoring fluid/electrolyte status

• Checking daily weights (especially in the mornings)

• Checking & being knowledgeable about the patient’s access (fistulas, catheters)

A day in the life of a renal nurse: http://www.istudentnurse.com/dialysis. Accessed July 21, 2015.


Care for Hemodialysis (HD)

• Monitor BP and pulse at least every 30 minutes

• Obtain weight before & after HD

• May need to infuse drugs via medication port during dialysis

• Obtain blood samples (urea nitrogen, creatinine, electrolytes)

• Monitor for hypotension

• Monitor fluid volume status



Care for Peritoneal Dialysis (PD)

• Maintain sterile technique

• Prevent infections

• Record fluid intake and output

• Record patient’s weight before & after procedure

• Promote dialysate drainage at the proper speed


Things for All Staff to Consider for CKD Residents

General medical care of patients on dialysis: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/general-medical-care-of-patients-on-dialysis/Default.htm. Accessed July 21, 2015.

General Nutritional Management

• Weight History

• Chewing/swallowing

• Feeding ability

• Diet order

• Labs

General Nutritional Management

• Fluid restrictions

• Educational needs

• Nutrient needs

http://www.lirebon.com/health/multiple-micronutrient-supplement

http://inmyskinnygenes.com



Nutritional Management for Long Term Care

In addition to general nutrition management, we want to assess and consider patients for,

• Liberalized diet

• Supplements

• N/V

• Loss of appetite

• C/D

http://www.canadiangirlruns.com/2015/01/lets-talk-about-vitamins/

Nutritional Management for Long Term Care

• Edema

• High BP

• High weight gain between dialysis treatments

• Education

Nutritional Challenges for CKD Patients in Nursing Home

• May only have one CKD diet option

• Special diets not always available

• Meal times not always flexible

-meals may be missed during dialysis treatment

• Poor food quality

• No substitution options for food items

Hulsebus-Colvin, J. (2015). The nutrition needs of patients with chronic kidney disease in health care community settings. Journal of Renal Nutrition: The Official Journal of the Council on Renal Nutrition of the National Kidney Foundation, 25(4), e31-e36. doi:10.1053/j.jrn.2015.04.004

Nutritional Challenges for CKD Patients in Nursing Home

• Protein needs may not coincide with protein in meals served

• Mediocre food quality

• Limited nutritional supplements in formulary

• Items that are low sodium in menu may contain potassium

• May not be giving phosphorus binders to patients

• Orange juice, Milk of Magnesia, and Prune juice may be given to patients

Hulsebus-Colvin, J. (2015). The nutrition needs of patients with chronic kidney disease in health care community settings. Journal of Renal Nutrition: The Official Journal of the Council on Renal Nutrition of the National Kidney Foundation, 25(4), e31-e36. doi:10.1053/j.jrn.2015.04.004

Nutritional Needs: Non-Dialysis

Non-Dialysis without DM: Stage 1-2

Non-Dialysis without DM: Stage 3-5

Non-Dialysis with DM: Stage 15-5

Energy 23-35 Kcal/kg 23-35 kcal/kg 23-35 kcal/kg

Protein 1.4 g/kg/d 0.6-0.8 g/kg/d 0.8-0.9 g/kg/d

McCann L, ed. Pocket Guide to Nutritional Assessment of the Patient with Chronic Kidney Disease. 4th ed. New York, NY: National Kidney Foundation Council on Renal Nutrition; 2009.

Nutritional Needs: Non-Dialysis

Hemodialysis(HD)

Peritoneal Dialysis(PD)

Energy 30-35 Kcal/kg >60 y.o.

35 kcal/kg <60 y.o.

30-35 Kcal/kg >60 y.o.

35 kcal/kg <60 y.o. or dialysate

Protein 1.2 g/kg/d if stable

1.2-1.3 g/kg/d if ill

1.2-1.3 g/kg/d

Byham-Gray L, Stover, J, Wiesen K. A Clinical Guide to Nutrition Care in Kidney Disease. 2nd ed. Chicago, Ill: American Dietetic Association; 2013.

Biochemical Parameters for CKD

Test Normal Range CKD

Creatinine 0.5-1.1 mg/dL for Female0.6-1.2 mg/dL for Male

2-15 mg/dL

Albumin 3.5-5 g/dL WNL for lab or > 4 g/dL

BUN 10-20 mg/dL 60-80 mg/dL who are well dialyzed and eating adequate protein

Phosphorus 3-4.5 mg/dL WNL

Potassium 3.5-5 mEq/L WNL 3.5-6 mEq/L

Byham-Gray L, Stover, J, Wiesen K. A Clinical Guide to Nutrition Care in Kidney Disease. 2nd ed. Chicago, Ill: American Dietetic Association; 2013.

Financial Help for Treatment of Kidney Failure

Federal

Medicare Part A (hospital): covers inpatient care, kidney transplantation, skilled nursing home residence, and hospice care.

Medicare Part B (outpatient): covers most dialysis treatments and supplies, health care provider fees, and anti-rejection medications for transplant.

Medicare Part D (medications)

Financial help for treatment of kidney failure: http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/financial-help-for-treatment-of-kidney-failure/Pages/facts.aspx. Accessed July 14, 2015.


Federal

• Social Security Disability Insurance (SSDI)

• Supplemental Security Income (SSI)



State

• Medicaid

• Medigap (Medicare Supplement)

• Medicare Savings Program

• Kidney Specific State Assistance Programs

• State Health Insurance Assistance Program (SHIP)



Special Populations

• U.S. Department of Veterans Affairs (VA)

• Military Service Members, Retirees, and Families: TRICARE for Life

• American Indians/Alaska Natives: The Indian Health Service

• Children: The Children’s Health Insurance Program (CHIP)

• People with Disabilities: Disability.gov



Private Organizations

• American Kidney Fund

-gives small grants to U.S. dialysis and transplant patients based on need.

• National Kidney Foundation

-may help with nutrition, transportation, medications, and scholarships.


References• A day in the life of a renal nurse: http://www.istudentnurse.com/dialysis. Accessed July 21, 2015.

• Assisted living and nursing home issues: http://www.cobar.org/repository/Public_Docs/slh/21_Assisted_Living_and_Nursing_Home_Issues.pdf. Accessed July 19, 2015.

• Bernstein, M., Munoz, N., & Academy of Nutrition and Dietetics. (2012). Position of the academy of nutrition and dietetics: Food and nutrition for older adults: Promoting health and wellness. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS, 112(8), 1255-1277. doi:10.1016/j.jand.2012.06.015

• Beto, J. A., & Bansal, V. K. (2004). Medical nutrition therapy in chronic kidney failure: Integrating clinical practice guidelines. Journal of the American Dietetic Association, 104(3), 404-409. doi:10.1016/j.jada.2003.12.028

• Byham-Gray L, Stover, J, Wiesen K. A Clinical Guide to Nutrition Care in Kidney Disease. 2nd ed. Chicago, Ill: American Dietetic Association; 2013.

• Dorner, B., & American Dietetic Association. (2010). Position of the american dietetic association: Individualized nutrition approaches for older adults in health care communities. J Am Diet Assoc, 110(10), 1549-1553. doi:10.1016/j.jada.2010.08.022

• Financial help for treatment of kidney failure: http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/financial-help-for-treatment-of-kidney-failure/Pages/facts.aspx. Accessed July 14, 2015.

References

• General medical care of patients on dialysis: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/general-medical-care-of-patients-on-dialysis/Default.htm. Accessed July 21, 2015.

• Hulsebus-Colvin, J. (2015). The nutrition needs of patients with chronic kidney disease in health care community settings. Journal of Renal Nutrition: The Official Journal of the Council on Renal Nutrition of the National Kidney Foundation, 25(4), e31-e36. doi:10.1053/j.jrn.2015.04.004

• Kamp, B., Amer Soc Nutr, Amer Dietet Assoc, Soc Nutr Educ, American Society for Nutrition, Society for Nutrition Education, & American Dietetic Association. (2010). Position of the american dietetic association, american society for nutrition, and society for nutrition education: Food and nutrition programs for community-residing older adults. J Am Diet Assoc, 110(3), 463-472. doi:10.1016/j.jada.2009.12.009

• McCann L, ed. Pocket Guide to Nutritional Assessment of the Patient with Chronic Kidney Disease. 4th ed. New York, NY: National Kidney Foundation Council on Renal Nutrition; 2009.

• National Kidney Foundation. (2015). Clinical practice guidelines for chronic kidney disease. www.kidney.org. Accessed July 9, 2015.

• Nursing homes (skilled nursing facilities): http://www.merckmanuals.com/home/older-people-s-health-issues/provision-of-care-to-older-people/nursing-homes. Accessed July 20, 2015.

• Tong, E. M., & Nissenson, A. R. (2002). DIALYZING THE ELDERLY: ISSUES AND CONCERNS: Dialysis in nursing homes. Seminars in Dialysis, 15(2), 103-106. doi:10.1046/j.1525-139X.2002.00033.x

• Twenty common nursing home problems and the laws to resolve them: http://www.commonwealthfund.org/publications/in-the-literature/2006/apr/twenty-common-nursing-home-problems-and-the-laws-to-resolve-them. Accessed July 14, 2015.

http://allnurses.com/geriatric-nurses-ltc/long-term-care-746461.html


ckd in the long term care setting presented by: mujan noroozian, utmb dietetic intern department of...

Documents

american dietetic association

health care communities

older adults

long term care facilities

long term care setting

diet assoc

medical nutrition therapy

chronic kidney failure