Case Analysis

 Anthropometric Assessment

5 months ago

Height: 5ft 4in / 162.5 cm / 1.63 m

Weight: 70 kg/ 154 lbs.

Usual weight: 55 kg/ 121 lbs.

DBW (NDAP): 122lbs

BMI: 27 kg/m2

% SBW 127%

Abwef AW+(IBW-AWx0.25)
66.3
 SUBJECTIVE GLOBAL ASSESSMENT (SGA) FORM

Fajardo

Joy

63

PKD
  Biochemical Assessment

Clinical Chemistry 5 months ago

 Increased Creatinine
 Increased Uric acid
 High LDL
 High triglyceride
 Present sugar in urine
 Present Proteins in urine

Interpretation

Elevated creatinine level signifies impaired kidney function or kidney disease. As the kidneys become
impaired for any reason, the creatinine level in the blood will rise due to poor clearance of creatinine by the
kidneys. Most of the time, a high uric acid level occurs when your kidneys don't eliminate uric
acid efficiently. Things that may cause this slow-down in the removal of uric acid include rich foods,. Also,
when Proteins and sugars are present in the urine, the filtering and the excretion of nitrogenous wastes are
impaired.

 Clinical Assessment
Patient has fluctuating BP ranging from greater than 120-140. Patient also experiences back
pain with stomach distention. Patient always feels bloated and has hematuria at times and
recurrent UTI since childhood

 Dietary Assessment (given)

 Food Item

Breakfast

Rolled oats
Eggs

Bread
AM Snack Coffee

Lunch

Beef w/ Brocolli
Mashed potato
Fried Chicken

Snack PM Soup
Champorado/Arroz

Dinner

Nepro Milk

Nutrition Diagnosis (Problem, Etiology, Signs and Symptoms) write as many as you can

Nutrition Intervention
Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring and evaluation
 Poor nutrition Patient will be given a food
Patient will be given
education proper nutrition diary to check on his daily
education and proper eating patterns and proper
related to
nutritional assessment food choices to further
poor eating to further improve the improve the patients
eating habits and nutritional status
habits as
lifestyle of the patient
evidenced by
the 24 hr
food recall

 Altered Patient will be given Patient will be instructed to do a

nutrition dietary modifications to blood chemistry once in a while to
related attend to the altered heck if the altered laboratory values
laboratory laboratory values. Patient were addressed
values related will be given a low purine
to increased diet to help with the case
nitrogenous of the patient
wastes in the
bloodstream
as evidenced
by the
biochemical
lab results

Food and nutrition Patient will be given a diet Patient will be given a short but
knowledge deficit consultation to attend to concise exam to test if the patient
related to poor diet the patient’s nutritional fully understood the nutrition
choices as evidenced knowledge deficit. Also education that was given by the
by the presence of by showing them the nutritionist dietitian
nitrogenous wastes foods that might affect the
in the lab results patient correlating to the
disease
Unintended weight Patient will be given Patient will be given a weight
gain related to the proper care and the diet monitoring diary to asses if te water
medical diagnosis of that will be given must be retention is addressed or unchanged
the patient as low in salt to prevent
evidenced by further water retention
distention, bloating
and water retention

Poor nutrition Patient will be given a Patient will be visiting the RND to
quality of life related proper meal schedule to check if the nutrition related
to work status of the change the patient’s eating problem was addressed
patient as evidenced pattern to address the
by poor food choices patient’s current nutrition
and weight related problem

Disordered eating Patient will be educated Patient will be given a food chart
pattern related to the on proper meal timing and and will be presenting the food
work status of the nutritional goals to recall to the consultant
patient as evidenced address the meal pattern
by PKD.MOV distortion and poor
nutrition quality

Impaired nutrient Patient will be given a diet Biochemical assessment must be

utilization related to that will lessen the kidney done and check due to the impaired
poor kidney filtration load to help the kidneys kidney filtration and to check if the
as evidenced by rest because of its stress kidney stress was reduced
Protein, glucose due to the patient’s
presence in condition
urinalysis
Dietary Management/Diet Rx: (NPC Method)

TER=55x30=1650-84-1566~1550
1550-200=1350(Overweight in BMI)

CHON=70x1.2=84
CHO=1350x0.7=945/4=235
FATS=1350x0.2=270/9=30
Sodium allowance:2g/day
Salt Allowance:5g/day
Fluid Allowance: 950ml
TCR: TPR: NPC:
Food # of Ex CHO, g CHON, g Fat, g Cal Na, mg K, mg Ca, mg Phos, mg Moisture
Item

Veg A 3 - 3.6 - 16.5 6 120 45

A.1
Veg B 1 - 0.6 - 16 8 100 15
B.1
Fruit A 2 20 2.4 - 80 6 240 20

Fruit B

Milk 1 12 8 - 170 160 400 360

Rice A 3 69 6 - 300 6 120 45

B
Rice C

Meat A 2 - 16 60 400 30 140

B.1
Meat B.2
B.3
Fat A 2 0 0 20 244 2 2 1
B
Sugar 3 15 0 15 120 4 1 2

Free
Foods
Total
 Diet Prescription
ALLOWANCE AMOUNT IN THE DIET
PLAN

KILOCALORIE 1350 1100

CARBOHYDRATES 235 130

PROTEIN 84 36

FAT 30 45

SODIUM

POTASSIUM

PHOSPHORUS

CALCIUM

FLUID
ONE DAY MEAL PLAN
MEAL TIME FOOD ITEM QUANTITY SAMPLE MENU
BREAKFAST
Malnggay ½C Sinabawang Gulay
Patola 1C
Ginger 1T
Rice 2C

AM SNACK Bread
Milk

LUNCH Oatmeal 2C Beets Patty Cordon bleu

Beets 1C
 Carrots 1c
Onion 1/4C
Garlic 3T
Rice 1C

PM SNACK Rice Congee

Ginger
Onion
Garlic

DINNER Lettuce Garden fresh

Onion salad
Carrots
Cucumber
Croutins

If any of you lacks wisdom, you should ask God, who gives generously to all without finding fault, and it will be given to you. James 1:5
God bless! 