ADIME TEMPLATE

NUTRITION ASSESSMENT

Patient name: Enez Joaquin

Age and gender: 24, female

Diagnosis: Stage 5 CKD

Pertinent medical history: Type 2 DM, Stage 3 CKD, normochromic anemia, normocytic anemia

Diet order:

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

Medications:

● Capoten/captopril 25 mg twice daily

● Erythropoietin (r-HuEPO) 30 units/kg
● Sodium bicarbonate 2 g daily
● Renal caps—1 daily
● Renvela—three times daily with each meal
● Hectorol 2.5 pg four times daily 3 times/week
● Glucophage (metformin) 850 mg twice daily
● Stool softener

Labs:

● Sodium: 130 (H)

● Potassium: 5.8 (H)
● Chloride: 91 (L)
● Phosphate: 6.4 (H)
● BUN: 69 (H)
● Creatinine: 12 (H)
● Albumin: 3.3 (L)
● Glucose: 282 (H)
● Triglycerides: 182 (H)
● GFR: 4 (L)

Weight: 170 lbs

Height: 5’0”

BMI: 33.2 (obese)

IBW: 100 lbs

%IBW: 170%

UBW (if pt has lost weight): 166 lbs

%UBW: 102%

% weight change (if pt has lost weight): +2.4%

Comments about weight history:

She has gained 4 kg the past 2 weeks

Nutrition-Focused Physical Assessment significant for: N/A

Summary of dietary intake and food preferences:

Overall low intake due to anorexia. Her current diet is low in simple sugar, and gives roughly 0.8
g/kg/day of protein and intake between 2-3 g of sodium. She has no known allergies, intolerances, or
aversions. Breakfast usually consists of cereal, bread or potatoes, coffee, and occasionally a fried egg.
Her typical lunch is a bologna sandwich, potato chips, and a coke. Dinner would normally be chile con
carne, Indian fry bread, and Iced Tea and she’ll have crackers with peanut butter as a snack. She is also a
daily drinker, consuming 1-2, 12 oz beers daily.

Nutrition Impact Symptoms:

Poor appetite due to anorexia, nausea, and vomiting

Nutrition Needs (provide range and factors)

Calories: 1488-1688 kcal/kg/day

● 35 kcal/kg/day

Protein: 27-45 g/day

● 0.6-1.0 g/kg/day

Fluids: 2000 mL

● 1000 ml + UOP
 ● UOP: 1000 mL

NUTRITION DIAGNOSIS: PES Statement (include diagnosis code)

Limited adherence to nutrition-related recommendations (NB-1.6) related to difficulty adhering

to a specialized diet when she was diagnosed with Stage 3 CKD as evidenced by inability to urinate, high
BUN, creatinine, potassium, and low albumin, sodium and GFR.

NUTRITION INTERVENTIONS

Food and/or Nutrient Delivery

Diet or nutrition support recommendations

● Intake 1488-1688 Kcal, 27-45 g protein where at least 50% is of high biological value
● No more than 2 L fluids a day, 2 g of K, 1 g of phosphorus, 2g of Na

Medications

● Renal Caps: Once a day

● Renvela with each meal
● Metformin: 850 mg twice a day with meals
● Hectorol: 2.5 pg 4 times a day, 3 days a week

Nutrition Education

Patient educated on the importance of high biological value proteins and their role in CKD.
Emphasize a diet of fruits, vegetables, and high biological value proteins rather than processed foods to
limit added sugar and sodium while also reducing calories. Patient educated on the importance of
limiting alcohol consumption, and alcohol's effect on the kidneys. If she still wants to drink alcohol,
encouraged to only drink a moderate amount.

Printed materials provided and reviewed

List of high biological value protein sources provided and reviewed

List of plant based protein sources provided and reviewed

Custom list of suggestions provided to implement nutrition goals and recommendations.

● Limit alcohol consumption to 2-3 drinks a week

● Meal replacement shakes such as Ensure BID if anorexia persists
● Substitute sugar sweetened beverages with water, tea, or artificially sweetened drinks if patient
chooses
 ● Substitute potato chips, white bread, and other food high in simple sugars with grains, fruits,
vegetables, and legumes to increase fiber intake and decrease blood sugar spikes

Goals

● Reduce caloric intake to 1488-1688 Kcal a day to assist in weight lose of 1.0-1.5 lbs a week until
patient reaches IBW of 100 lbs
● Limit daily sodium intake to 1.5-2.0g/day to prevent fluid overload and further edema
● Ensure half of protein consumed comes from high biological value sources such as poultry, fish,
meat, and soy

NUTRITION MONITORING and EVALUATION

3 day food record to ensure diet adherence of high biological value proteins, and reduced alcohol and
sodium consumption

Monitor weight loss again every 2 weeks for the next 6 months

Assess fasting blood sugar levels every 2 weeks to check for reduction and stabilization

Assess GFR for improvements in 6 months

NAMES, DATE, AND TIME

Sean Singh

Justin Poplin

4/6/22, 4:00 PM