Patient Name: ​Joaquin, Enez

Referring Physician​ L. Nila

Age ​24 yo Gender ​Female​ Height ​60 in / 152.4 cm​ Weight ​170 lbs / 77.3 kg

ASSESSMENT

Demographics:

1. Ethnicity: Native American (Pima Indian)

2. Family History: Parents have T2DM
3. Primary Care Provider: Reservation Health Services

Food Allergies: NKFA

Admission Diagnosis: N/A

Weight History: 4-kg weight gain in the past 2 weeks

Weight Goal: N/A

Usual Weight: 161 lbs, 73.3 kg

%Usual Body Weight: 105%

Ideal Weight: 100# / 45.5 kg

%Ideal Body Weight: 161% (Obese)

Adjusted Body Weight: 124.6 # / 56.5 kg

BMI: 31.4 kg/m​2 ​(Obese)

Activity level: Sedentary

Nutrition Focused Physical Findings:

Skin: Dry-yellowish brown

Extremities: 3+ pitting edema to knees
Neurologic: asterixis
Appetite: Anorexia
Medications:

Glucophage, 850 mg twice daily

Past Medical History

1. Diagnosed with Stage 3 chronic kidney disease 2 years ago. Acute symptoms developed
over the last 2 weeks
2. Recently stopped taking prescribed hypoglycemic agent & has never filled prescription
for anti-hypertensive medication
3. Declining GFR, increasing creatinine and urea concentrations, elevated serum
phosphate, and normochromic, normocytic anemia
4. Being admitted for kidney-replacement therapy
5. Family history of T2DM

Relevant Lab Values

1. Sodium 130 mEq/L (136-145 mEq/L)

2. Potassium 5.8 mEq/L (3.5-5.1mEq/L)
3. Phosphate 6.4 mg/dL (2.2-4.6 md/dL)
4. BUN 69 mg/dL (6-20 mg/dL)
5. Creatinine serum 12.0 mg/dL (F 0.6-1.1 mg/dL)
6. Est GFR 4 mL/min/1.73m​2​ (>60 mL/min/1.73m​2​)
7. Glucose 282 mg/dL (70-99 mg/dL)
8. Protein, total 5.9 g/dL (6-7.8 g/dL)
9. Albumin 3.3 g/dL (3.5-5.5 g/dL)
10. RBC 3.1 x 10​6​/mm​3​ (F 4.2-5.410​6​/mm​3​)
11. Hcb 10.5 g/dL (F 12-16 g/dL)
12. Hct 33% (F 37-47%)
13. HbA1c 9.2% (<5.7%)
14. pH urinalysis 7.9 (5-7)
15. Protein urinalysis +2 mg/dL (neg)

Nutrient Requirements:

Energy: 1,978 kcal/day (35 kcal/kg/day using adjusted weight 56.5 kg)

Protein: 45.2 PRO/day (0.8 g pro/kg/day using adjusted weight 56.5 kg)

Fluid needs: 1,000 mL + urine output

Nutrient Intake:

Based on 24-hr recall, the patient consumes a high amount of processed foods, high
sodium, and high phosphorus diet. Patient also reports that she consumes alcohol 1-2
beers daily.

Current Diet Order:

Diet PTA low simple sugar, 0.8 g protein/kg of body weight, 2-3 g Na

35 kcal/kg, 1.2 protein/kg, 2 g K, 1 g phosphorus, 2g Na, 1000mL fluid + urine output per
day

NUTRITION DIAGNOSIS

Altered nutrition-related laboratory values (NC - 2.2) R/T uncontrolled T2DM and renal
dysfunction AEB high blood glucose (282 mg/dL), high Na (130 mEq/L), high K (5.8 mEq/L),
high P (6.4 mg/dL), low albumin (3.3 g/dL), and excess protein, glucose and ketones in urine.

NUTRITION INTERVENTION

1. Food and/or Nutrient Delivery

a. Limit sodium intake
i. No additional salt when cooking, avoid processed foods
b. Limit potassium intake
c. Limit phosphorus intake
i. Avoid meats, dairy products, nuts, and chocolate
d. Limit fluid intake to 1000 mL + output/d
i. Avoid coffee, ice tea, ice cream, soup
ii. REC drinking liquids at room temperature, sugar-free tart candies
e. REC limiting dairy intake to one serving per day
f. REC avoiding alcohol consumption
g. REC PRO sources with high biological value
i. Fish, Poultry, Eggs
h. REC compliance with medications
2. Nutrition Education
a. REC renal diet education
3. Coordination of Care
a. Refer to social worker
4. Nutrition Counseling/Goals
a. Biochemical markers/lab values within normal ranges
i. BG: <200mg/dL
ii. Na: 136-145 mEq/L
iii. K: 3.5-5.1mEq/L
 iv. P: 2.2-4.6 md/dL
v. Albumin: 3.5-5.5 g/dL
b. Weight changes
i. Lose 0.5 to 1 lbs per week until normal BMI is reached
ii. Avoid 5% fluid weight gain in between dialysis treatment

NUTRITION MONITORING/EVALUATION

1. M/E biochemical markers all relevant lab values, presence of edema, and weight
changes.
a. Follow-up between 1 - 3 days

RD Signature: Date: 11/6/2019

Lauren Okamoto
Amy Nguyen
Jazmine Melchor
Ranielle Soriano