Nutrition Database

This assignment is intended to collect information and apply Medical Nutrition Therapy related knowledge to a disease condition. All data will be kept confidential and anonymous, no patient names, initials,

room numbers, birth dates, or other personal identifiers will be collected.

Intern Name Megan Lasko Clinical Core Rotations: Basic / Intermediate / Advanced

Patient Age73 Sex Male Female Your Assessment Date 1/24/17 Admit date 1/23/17

Admitting Diagnosis Near Syncopal Episode

Prior Medical History CKD Stage III, T2DM (diet controlled - was on oral medication, but was able to discontinue d/t

good diet), aortic stenosis and A. fib s/p atrial valve replacement (Nov 2016), HTN, HLD, h/o vitamin D deficiency

Diet Order RENAL: Pre-Dialysis Supplements None

If applicable, describe food intake since admission or past 5 days (use percentages, expressed as a range or an average,

describe other pertinent issues or if common in facility mark checkbox on right to specify) Good Fair Poor

The patient was assessed not even a full 24-hours after admission, but when I saw him, he had ordered and consumed that day’s

breakfast and lunch trays. He and his wife made comments about how small the portions were and regarding the restrictiveness of

the pre-renal diet, but he was consuming 100% of his meals. Prior to admission, he was eating fine and had a good appetite,

regularly consuming the meals and snacks that were prepared for him by his wife. Because his at-home diet history was pertinent in

his nutrition care process, I will include it below. The following is his typical daily intake:

Breakfast: 1) Oatmeal w/ Splenda, brown sugar, sugar-free syrup, and blueberries OR 2) Wheat pancakes + blueberries and sugar-

free syrup OR 3) Scrambled eggs: 2 egg whites + 1 yolk OR 4.) Omelet – Drinks: cup of coffee and/or diet cranberry juice or orange

juice

Lunch: Turkey medallions, yogurt, and a fruit (bananas, cantaloupe)

Dinner: Turkey/chicken/fish, baked sweet or regular potato, and a fresh vegetable (asparagus, broccoli) + big salad on the side

(green leaf lettuce, tomatoes, radishes, cucumbers, red onion)

HS Snack: 1) Yogurt OR 2) sugar-free Klondike bar OR 3) No-salt potato chips OR 4) Diet pudding

Drinks 4-6 bottles of water w/ crystal light/day

Per wife: She tries to get 3 servings of fruit and 2 servings of dairy in daily

Any Food Allergies / Intolerances? No

Height and Weight: HT (in inches and cm) 66 inches, 167.7 meters Current WT (in pounds and kg) 160 lb, 72.7 kg

BMI 25.87 kg/m2

How was height obtained? Stated by patient How was weight obtained? Scale

Ideal Body Weight (IBW) 142 lb, 64.5 kg % IBW 113% Usual Body Weight (UBW) 165 lb,75 kg

% UBW 97%

Nutrition Database

If the patient had a weight change, indicate this in pound and kg and % gained/lost and the timeframe. Was this

unintentional or intentional? Give the reason(s). Using the cutoff-percentages was this loss/gain significant?

The patient had a 5 lb, 2.3 kg, 3% weight loss x 2 months d/t the recovery process of his open heart surgery in

November 2016 (per wife report). This is not significant weight loss.

if applicable Dry Weight (in pounds and kg) N/A

if applicable in your facility: What is the patient’s adjusted weight (in pounds and kg) N/A

Social History (occupation, marital status, support system at home, alcohol use, who prepares meal, food secure / insecure, etc.)

The patient retired in 2010 (occupation not specified). He is married and lives with his wife, who works very hard to

prepare meals for the patient that best manage his multiple disease states (as per diet history above). The two

received DM and cardiac diet education in 2014. He participates in cardiac rehab s/p AVR that was performed in

November 2016.

Advance Directive: Yes No Nutrition related implications? N/A

Skin Integrity / Chewing and Swallowing Ability / Misc. Info

Is Patients Skin Intact? Yes No Braden Score 23 PUSH Score n/a

If no, what is present? Surgical Wound Decubitus Ulcer

Does the patient have Edema if pitting, state stage and site Ascites

If decubitus ulcer, list stage (I-IV) and site(s)

If decubitus ulcer, is it Improving? Getting worse?

Incontinent of urine? Yes No (Patient’s 12-hour urine output was 1200 mL, 18 hours: 2050

mL)

Urinary catheter? Yes No output in mL over past 24 hours mL

Date of last BM & consistency Not noted; RN charting “No” for bowel incontinence Bathroom privileges Yes

No

Nutrition Database

Are any of the following present? Nausea Vomiting Diarrhea Constipation

Difficulty Chewing Difficulty Swallowing

Own teeth Edentulous

Dentures? Yes No Fit well? Yes No

Unable to feed self Malabsorption

Early Satiety Taste Changes

Is patient on dialysis? Yes No if yes, what type Schedule

Is patient on a ventilator? Yes No

Most recent blood pressure 142/85 is BP stable? Yes No BP stable by the time of discharge, but there

were many fluctuations during his hospital stay. He was admitted for a syncopal, hypotensive episode which was

treated with IV fluids in the ER where his BP returned to normal (150/74). Episodes of hyper and hypotension

are noted during his short stay. Patient’s PMH positive for HTN. Usual diuretic regimen was put on hold during

stay.

Most recent temperature 98.2°F

Is patient receiving IV Fluids? Yes No if yes, what type / rate / total volume in past 24 hours

If applicable, how many g Dextrose and kcal does this provide? N/A

Pertinent Medications (list medications, state what they are used for, and if applicable nutritional implications)

Drug name(s) Indication Nutritional Implication / food Interaction

Apixaban (Eliquis) 2.5 mg oral BID*

Patient’s hx of A. fib: Prevention of stroke/systemic embolism in A. fib

Diet implications: avoid herbal products that have anti-coagulant effects (i.e. ginger, garlic, ginseng, etc.), avoid SJW, Caution w/ grapefruit/related citrus and caution w/ Vitamin E

ASA 82 mg chewable Patient’s hx of cardiac disease and hyperlipidemia: Platelet Aggregation Inhibitor – to prevent CVA or MI

Diet Implications: Pt should be adequately hydrated (adequate fluid intake), Avoid/limit natural products which affect coagulation, Limit caffeine to ↑ GI effects, ↑ Vit C and Folate w/ LT high dose Nutritional implications: anorexia

Nutrition Database

Atorvastatin (Lipitor) 40 mg tablet

Patient’s hx of hyperlipidemia: Anti-hyperlipidemic (pt w/ hx HLD), ↓ risk of cardiovascular events

Diet implications: Decrease fat and cholesterol in the diet, and if needed, calories. Caution w/ grapefruit and related citrus

Bisoprolol (Zebeta) 10 mg tablet

Patient’s hx of HTN: Anti-hypertensive Diet implications: Possible need for low sodium, low calorie diet. Avoid natural licorice.

Cholecalciferol (vitamin D3 po) 1000 mg by mouth

Patient has hx of Vitamin D deficiency in setting of CKD III: Vitamin supplement/Calcium regulator – maintenance of serum D levels and increase Ca absorption

Nutrition Implications: increases Ca absorption, may cause anorexia, weight loss, and increased thirst Oral/GI symptoms: dry mouth, metallic taste, N/V, constipation, diarrhea

Fenofibrate (Triglide) 160 mg tablet

Patient hx of hyperlipidemia: anti-hyperlipidemic (to treat high cholesterol and/or high cholesterol)

Diet Implications: low fat, low cholesterol diet – possibly low calorie diet – recommended Triglide should not be given to patients with an egg allergy

Furosemide (Lasix) 20 mg tablet**

Patient hx of HTN: anti-hypertensive (loop diuretic)

Diet implications: ↑ dietary K and Mg (or K, Mg supplement); ↓ kcal and Na. Avoid natural licorice. Nutrition Implications: anorexia, increased thirst

Amiodarone 200 mg tablet

Patient’s hx of A. fib: anti-arrhythmic Diet Implications: avoid grapefruit/related citrus, avoid SJW Nutrition Implications: anorexia May cause abnormal taste, smell and salivation

Potassium Chloride (K-dur) 20 mEq tablet

To maintain serum K levels b/c patient is on Lasix, a K-depleting diuretic: an electrolyte/mineral supplement

Diet Implications: not w/ salt substitutes – may contain additional K. Because patient has CKD and compromised potassium excretion capabilities, he should also be aware of dietary K sources.

Torsemide (Demadex) 20 mg tablet

Patient hx of HTN: anti-hypertensive (loop diuretic)

Diet implications: ↑ dietary K and Mg (or K, Mg supplement); ↓ kcal and Na. Avoid natural licorice. Nutrition Implications: anorexia, increased thirst

*Apixaban (Eliquis) was the only hospital-administered medication. The remainder of the medications listed are

part of the patient’s home medication regimen.

**Lasix was discontinued for duration of hospital stay d/t patient’s admitting diagnosis of a near syncopal

episode.

Nutrition Database

Nutrition related laboratory values

Lab Test

Lab values list all that are available –

indicate if abnormal high or low ( or )

and if applicable, state if they are

trending up or down.

Nutritional significance if abnormal Can a nutrition intervention help to correct this abnormal lab value? How?

Na 142 (WNL) – trending up

K

4.4 (WNL) trending down (was 6.1 [elevated] on admission)

Although normalized by the time of assessment, hyperkalemia is still a concern for this CKD, non-dialysis patient. Nutritional significance if abnormal: Could be due to excessive dietary intake of potassium. The patient’s diet history revealed he has an affinity for high-K foods (i.e. bananas (1-3/day), tomatoes, cantaloupe, etc.). Can a nutrition intervention help to correct this abnormal lab value: Yes – in fact, we were consulted to see this patient to help him incorporate a CKD-appropriate diet into the DM and CVD diets which he was already following. Part of the nutrition intervention for this patient was diet education regarding reducing dietary potassium.

BUN 23 (WNL) trending up

CREAT

1.51 (high) trending down (was 2.03 on admission)

Nutritional significance if abnormal: CKD diet education may be warranted in order to attenuate the progression of the declining kidney function, which would be indicated by increasing baseline serum creatinine levels. Can a nutrition intervention help to correct this abnormal lab: Although it may not correct the lab, education and subsequent patient adherence to CKD diet education recommendations may help to prevent declining kidney function. In terms of serum creatinine, a lower value would indicate improvements in kidney function.

GFR

45.5 (stage 3 CKD) trending up (was 32.4 on admission)

Nutritional significance if abnormal: CKD diet education may be warranted in order to attenuate the progression of the declining kidney function, which would be indicated by decreasing GFR. Can a nutrition intervention help to correct this abnormal lab: Although it may not correct the lab, education and subsequent patient adherence to CKD diet education recommendations may help to prevent declining kidney function. In terms of GFR, maintenance of the current GFR would indicate no progressive decline.

Nutrition Database

Albumin N/A

Prealb N/A

CRP N/A

Glucose 87 (WNL) trending down

HgbA1C N/A – was 6.0% 3 months ago

H/H

10.2/33.5 (low) – trending down

Nutritional significance if abnormal: May indicate dietary iron deficiency. Likely multi-factorial and related to patient’s hemolytic state upon admission and renal disease. Can a nutrition intervention help to correct this abnormal lab: Recommendations for medications like EPOGEN, or iron supplements, might be beneficial. Educational intervention in which iron-rich food sources are discussed.

MCV

76 (low)- trending up

Nutritional significance if abnormal: May indicate dietary iron deficiency. Can a nutrition intervention help to correct this abnormal lab: Same as noted for “H/H” above.

MCH

23.1 (low) – trending down

Nutritional significance if abnormal: May indicate dietary iron deficiency. Can a nutrition intervention help to correct this abnormal lab: Same as noted for “H/H” above.

Iron (Fe) N/A

Transferrin Sat (%) N/A

Ferritin N/A

Vitamin B12 N/A

Folate N/A

Ca

9.5 (WNL) trending down (was 10.3 [elevated] on admission)

Phos

N/A – My preceptor and I made recommendations to obtain Phos and Mg labs to assess if we should push to liberalize the patient’s diet. The MDs put the order in for these labs,

Nutrition Database

but he was discharged before they were obtained.

Mg See above

Total Cholesterol N/A

LDL N/A

HDL N/A

TG N/A

ALT N/A

AST N/A

Alkaline Phos N/A

Total Bilirubin N/A

Amylase N/A

Lipase N/A

BNP N/A

Troponin or CK 0.00 (WNL) – trending down

Other relevant labs (e.g. ammonia, blood gases, AIDS/HIV related, etc.)

POC blood gases (taken b/c “slightly hemolyzed”) – taken b/w initial and next-day labs

- Potassium I-STAT: 5.4 mmol/L (still slightly high: normal: 3.5-5.3)

- Calcium IONIZED: 1.33 (high: normal is 1.12-1.32 mmol/L)

- BUN I-STAT: 30 mg/dL (high: normal 5-25)

- Creatinine i-stat: 2.2 mg/dl (high: normal 0.6-1.3)

Nutritional Needs

What weight will you be using to calculate needs and why? I will use that patient’s actual body weight - 160 lb, 72.7 kg

– because patient is not morbidly obese or presenting w/ noted fluid retention.

Any stress factors 1.1 (most often, we use 1.1 in my facility assuming that inpatient status suggests the person is under

some type of metabolic stress. For example, this patient was experiencing acute kidney injury on CKDIII), activity

factors to consider? 1.3; daily activity per patient interview appears normal; does participate in cardiac rehab

Note: Understand the difference between resting energy expenditure and total energy expenditure. If you have a stressed

patient, you are likely to use a stress factor. If your patient is in bed moving around and alert, you will likely have to pick an

activity factor for Harris Benedict and Mifflin St.Jeor.

Nutrition Database

Calculate Total Energy needs using three of the five methods below. Show your work. Work shown below

1) Harris-Benedict ------------------------------------ 2000 kcal

2) Mifflin St. Jeor -------------------------------------- 2000 kcal

3) kcal/kg ----------------------------------------------- 1950 kcal

4) Ireton Jones (only use in critically ill) ------- kcal

5) Penn State 2010 equation ---------------------- kcal

Work:

Height: 167.7 meters

Weight: 72.7 kg

Harris-Benedict: Men: RMR = 66.47 + 13.75 X weight + 5.0 X height – 6.75 X age

RMR=66.47 + (13.75 X 72.7) + (5 X 167.7) – (6.75 X 73)

RMR=66.47 + (999.625) + (838.5) – (492.75)

RMR=1411.845 1412 kcal/day=RMR

TE: RMR X SF X AF 1412 X 1.1 X 1.3=2019 kcal/day – rounded to nearest 50 kcal 2000 kcal/day=TE needs

Mifflin St.Jeor: Men: RMR = 9.99 X weight + 6.25 X height – 4.92 X age + 5

RMR=(9.99 X 72.7) + (6.25 X 167.7) – (4.92 X 73) + 5

RMR=(726.273) + (1048.125) – (359.16) + 5

RMR= 1420.238 1420 kcal/day=RMR

TE: RMR X SF X AF 1420 X 1.1 X 1.3=2030.6 kcal/day – rounded to nearest 50 kcal 2000 kcal/day=TE needs

Kcal/kg:

25-30 kcal/kg for weight maintenance – will use a value in the middle 27 kcal/kg

27 kcal/kg x 72.7 kg=1962.9 kcal – rounded to nearest 50 kcal 1950 kcal/day

What formula did you ultimately use for the Pt & why? I used 27 kcal/kg. At my facility, we typically use the kcal/kg

method unless a patient is >125% of their ideal body weight, in which case we use Mifflin St. Jeor (subtracting 500-

1000 kcal for weight loss). Also, the AND Nutrition Care Manual recommends that in adults w/ CKD not on dialysis, a

range of 23-35 kcal/kg be used to determine energy needs. I chose 27 kcal/kg because this patient participates in

cardiac rehab and is still very ambulatory and competent in ADLs.

Calculate Protein needs

How many g/kg would you use & why? 0.8 g/kg – as recommended by the AND Nutrition Care Manual for adults w/

CKD not on dialysis (range of 0.6-0.8 g/kg). I chose the higher end of the range because the patient participates in

cardiac rehab-related physical activity, and, as mentioned before, my facility assumes the energy/protein needs are

on the higher end of recommendations when a patient is of inpatient status.

Show your work:

0.8 g/kg X 72.7 kg=58 g protein

Nutrition Database

58 g/day

Calculate Fluid needs using two of the four methods below. Show your work. Work below

1) ml/kg depending on age ----------------- ml/day

2) Holliday-Segar method ------------------- 1204 ml/day

3) RDA method --------------------------------- 1950 ml/day

4) urine output (urine out +500ml/day)- ml/day

Work:

1) Holliday-Segar method:

a. 100 millileters (mL) per kilogram (kg) body weight for 1st 10 kg

i. 100 mL +

b. 50 mL per kg body weight for next 10 kg

i. 50 mL +

c. 20 mL per kg body weight for each kg above 20 kg

i. 72.7-20=52.7 kg

ii. 150 mL + (20 X 52.7)=1204 ml

2) RDA method: 1 ml/kcal 1950 kcal needs x 1 ml/kcal=1950 ml

What formula did you ultimately use for the Pt & why?

I used the RDA method. The pre-renal diet order at my facility does not have a “built-in” fluid restriction, and it is up to

the physicians to decide whether the patient’s medical status warrants a fluid restriction. Because he was admitted

for a hypotensive incident, was not noted to have any fluid retention, and because his urine output was adequate

(~1200 ml/12 hours), the MDs did not mention fluid restriction for this patient and therefore the RDA method

should be sufficient.

Interaction with the IDT (Interdisciplinary Team)

Indicate if you had interactions with any of these other health care team members while providing nutrition care / patient care

Describe interactions with or referrals made to any of these health care team professionals:

Nursing (RN)

Physician (MD)

Spoke with the attending internal medicine physician about liberalizing the patient from a “pre-renal” to a “cardiac step 1 + 2 (or 3) g K” diet regimen.

Nutrition Database

He agreed to order a P and Mg lab, and said we would discuss changes to the patient’s diet order from there. My preceptors feel that the “pre-renal” diet order is often unnecessarily restrictive for renal patients in the inpatient setting. The pre-renal diet includes a very strict phosphorus restriction, which seemingly wasn’t necessary for this patient at this time. The cardiac step 1 and 2 g K diet combination would have likely placed all the restrictions required for this patient’s stay while easing up on the protein and phosphorus allowances.

Social Worker (SW)

Speech Therapist (ST/SLP)

Physical Therapist (PT)

Occupational Therapist (OT)

Respiratory Therapist (RRT)

Woundcare / Ostomy Nurse

Physician’s Assistant (PA)

Other

Provided information pamphlet for my facility’s outpatient MNT services (which are covered by most insurance plans). I informed the patient’s wife that the outpatient dietitian would be able to help more thoroughly plan and adjust the patient’s home diet regimen according to changes in lab values/other medical indices, rather than the brief overview that was provided to him by me during inpatient stay.

Nutrition Diagnosis (P-E-S) Statement (write 2)

Problem: Food and nutrition-related knowledge deficit

related to (Etiology): lack of previous renal diet education

as evidenced by Signs and Symptoms: per interview w/ patient and his wife: stated unfamiliarity with nutrients to limit

(potassium, phosphorus, protein).

Problem: Excessive mineral intake (potassium)

Nutrition Database

related to (Etiology): patient’s high affinity for high-potassium foods (bananas, cantaloupe, tomatoes, potatoes) in

setting of reduced renal function (CKD III)

as evidenced by Signs and Symptoms: per patient interview and a serum potassium 6.1 mmol/L on admission.

Interventions (your recommendation as a dietetic intern)

Nutrition team will provide patient with verbal renal nutrition education about potassium-rich foods (in

particular, those present in the patient’s regular diet as obtained from diet history) and ways to replace, reduce

and/or remove them from the diet in order to address patient’s elevated potassium levels.

o *Note: Potassium was the focus of the renal diet education because the patient’s potassium levels were

high on admission, and his diet history indicated this was the biggest issue w/ his diet. His diet was

otherwise low in sodium, saturated fat, and carbohydrate-controlled (d/t previous DM and cardiac diet

ed in 2014), and was not significantly high in phosphorus- or protein-rich foods. We did request a P lab

be ordered to indicate if we should continue with low Phos education, but he was discharged before it

was obtained. In summary, we decided to stick with low K diet ed (with brief mention of P foods) so as

to not overwhelm the patient. As noted above, we saw referral to our outpatient MNT RD as most

appropriate for any further diet education needs.

Nutrition team will provide renal diet nutrition education via educational handouts identifying potassium-rich

foods and their respective serving sizes and milligram potassium amounts. This will be provided in combination

with an individualized nutrition prescription delineating patient’s recommended daily potassium intake (<3

gm/day).

Nutrition team will recommend patient’s diet order is changed from “pre-renal” to “step 1 cardiac + 2 gm K”.

This will facilitate a modified fat, cholesterol, fiber, sodium, and potassium diet in order to liberalize the

patient’s diet according to his individual clinical profile without compromising the nutritional requirements and

restrictions indicated by his disease states.

Nutrition team will provide referral to outpatient MNT RDN in order for patient to receive more individualized

and comprehensive renal, DM, and cardiac diet education.

Nutrition Prescription

1950 kcal, 60% CHO (292 g), 12% PRO (58 g), 28% Fat (61 g), 7% SFA (15 g), 9% PUFA (20 g), 12% MUFA (26 g),

<2.4 g Na, <3 g K, 28 g fiber, <2g Ca, 1500 IU vitamin D3. No P or fluid restrictions unless the need becomes

indicated medically.

Nutrition Goals

Patient and wife will demonstrate understanding of renal diet education through verbal teach-back of 3 high-K

foods currently present in the patient’s diet, 3 low-K fruits for replacement, and the daily K recommendation for

Nutrition Database

this patient (mg amount).

Patient will schedule appointment with outpatient RD within 2 weeks after discharge to more adequately meet

diet education needs.

Monitoring and Evaluation (how do you monitor this patient, how do you measure progress?)

Patient and wife will accurately name 3 high-K foods currently present in the patient’s home diet. (bananas,

tomatoes, cantaloupe, potatoes).

Patient and his wife will accurately name 3 low-K fruits that can adequately replace the high-K fruits currently

present in the patient’s daily diet.

Patient and wife will accurately state the daily K intake recommendation for this patient. (<3 g/d)

Nutrition care team will contact outpatient RD to confirm patient has scheduled appointment.

Discharge Planning (if applicable): List your recommendations / interventions / plan if your patient is being

discharged back home to live alone or with family or if transferred to an assisted living / long-term care facility.

No discharge planning other than the referral to the outpatient RD.

Anything else interesting about this patient (e.g. any lab tests or surgical procedures/tests that you were not

familiar with)?

o Through this patient’s hospital course, I learned about the purpose of the i-STAT blood analysis. The

MDs were charting that his blood was “slightly hemolyzed”, and thus they had to do a “repeat i-STAT”

exam taken from a vein to get more accurate lab value data. The i-STAT found the patient’s K levels to

5.4 – which is still considered high, but is not as elevated as the original value of 6.1.

o While I felt I should have chosen a tube feed or TPN patient for this assignment (I have been doing

plenty lately!), I chose this patient because performing renal diet education is something of which I have

always been a little bit fearful. I always feel as if there is so much information to throw at the patient

and am fearful of overwhelming the patients and of the questions they might ask. Therefore, when I

saw the doctor’s consult for nutrition services for “renal diet education: patient having trouble

incorporating it into DM and cardiac diet”, I knew it was the perfect opportunity to face my fears. My

preceptors were really helpful, as they guided me through the process and taught me that each renal

diet education requires a lot of info-gathering about that individual patient (for it to be most beneficial

to the patient). For example, this patient had hyperkalemia on admission, but his urine output was fine,

and his diet history indicated a diet not particularly high in P or protein (the wife had this patient’s DM

Nutrition Database

and cardiac diets down to a near-perfect science). Therefore, so as to not overwhelm the patient and his

wife, we focused on the potassium aspect of the diet education, because this seemed to be the biggest

problem for this patient. I liked that the patient and his wife were very receptive, which seems to rarely

be the case in the clinical setting. I thought it was a good example of how clinical diet education can

make a difference, and in my eyes, this was a complicated patient because it taught me how to execute

renal diet education based on the patient’s individual clinical profile.