Patient Summary: Mrs. Joaquin is a 24-yo Native American woman who was diagnosed with type 2 DM when she
was 13 years old and has been poorly compliant with prescribed treatment.
History:
Onset of disease: Diagnosed with Stage 3 chronic kidney disease 2 years ago. Her acute symptoms have developed
over the last 2 weeks.
Medical history: Gravida 1/ para 1. Infant weighed 10 lbs at birth 7 years ago. Pt admits she recently stopped taking
a prescribed hypoglycemic agent, and she has never filled her prescription for anti-hypertensive medication.
Progressive decompensation of kidney function has been documented by declining GFR, increasing creatinine and
urea concentrations, elevated serum phosphate, and normochromic, normocytic anemia. She is being admitted for
preparation for kidney-replacement therapy.
Surgical history: No surgeries
Medications at home: Glucophage (metformin), 850 mg twice daily
Tobacco use: No
Alcohol use: Yes, 12 oz beer daily
Family history: What? T2DM. Who? Parents
Demographics:
Marital status: Married—lives with husband and daughter; Spouse name: Eddie
Number of children: 1
Years education: High school
Language: English and Akimel O’odham (Pima)
Occupation: Secretary Hours of work: 9–5 Ethnicity: Pima Indian Religious affiliation: Catholic
Admitting History/Physical:
Chief complaint: Pt complains of anorexia; N/V; 4-kg weight gain in the past 2 weeks; edema in extremities, face,
and eyes; malaise; progressive SOB with 3-pillow orthopnea; pruritus; muscle cramps; and inability to urinate
General appearance: Overweight Native American female who appears her age; lethargic, com- plaining of N/V.
Vital Signs:
Temp: 98.6
Pulse: 86
Resp rate: 25
BP: 220/80
Height: 5'0"
Weight: 170 lbs
Heart: S4, S1, and S2, regular rate and rhythm. I/VI systolic ejection murmur, upper-left sternal border.
HEENT: Head: Normocephalic, equal carotid pulses, neck supple, no bruits Eyes: PERRLA
Ears: Noncontributory
Nose: Noncontributory Throat: Noncontributory
Genitalia: Normal female
Neurologic: Oriented to person, place, and time; intact, mild asterixis Extremities: Muscle weakness; 31 pitting
edema to the knees, no cyanosis Skin: Dry and yellowish-brown
Chest/lungs: Generalized rhonchi with rales that are mild at the bases (Pt breathes with poor effort)
Peripheral vascular: Normal pulse (31) bilaterally L
Abdomen: Bowel sounds positive, soft; generalized mild tenderness; no rebound
Nursing Assessment
3/5
Abdominal appearance (concave, flat, rounded, obese, distended)
rounded, obese
Palpation of abdomen (soft, rigid, firm, masses, tense)
soft
Bowel function (continent, incontinent, flatulence, no stool)
continent
Bowel sounds (P5present, AB5absent, hypo, hyper)
RUQ
P
LUQ
P
RLQ
P
LLQ
P
Stool color
brown
Stool consistency
formed
Tubes/ostomies
N/A
Genitourinary
Urinary continence
N/A
Urine source
N/A
Appearance (clear, cloudy, yellow, amber, fluorescent, hematuria, orange, blue, tea) N/A
Integumentary
Skin color
light brown
Skin temperature (DI5diaphoretic, W5warm, dry, CL5cool, CLM5clammy, CD 15
cold, M5moist, H5hot)
W
Skin turgor (good, fair, poor, TENT5tenting)
good
Skin condition (intact, EC5ecchymosis, A5abrasions, P5petechiae, R5rash,
W5weeping, S5sloughing, D5dryness, EX5excoriated, T5tears, SE5subcutaneous
emphysema, B5blisters, V5vesicles, N5necrosis)
intact, A
(Continued)
Nursing Assessment (Continued)
Nursing Assessment
3/5
Mucous membranes (intact, EC5ecchymosis, A5abrasions, P5petechiae, R5rash,
W5weeping, S5sloughing, D5dryness, EX5excoriated, T5tears, SE5subcutaneous
emphysema, B5blisters, V5vesicles, N5necrosis)
intact
Other components of Braden score: special bed, sensory pressure, moisture,
activity, friction/shear (.18 5 no risk, 15–16 5 low risk, 13–14 5
activity, 16
moderate risk, #12 5 high risk)
Orders:
Evaluate for kidney replacement therapy 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 µg four times daily 3 times/week Glucophage (metformin)
850 mg twice daily
35 kcal/kg, 1.2 g protein/kg, 2 g K, 1 g phosphorus, 2 g Na, 1000 mL fluid 1 urine output per day CBC, chemistry
Stool softener Occult fecal blood Nutrition consult
Nutrition:
History: Intake has been poor due to anorexia, N&V. Patient states that she tried to follow the diet that she was
taught two years ago. “It went pretty well for a while, but it was hard to keep up with.”
Usual dietary intake:
Breakfast: Cold cereal
Bread or fried potatoes Fried egg (occasionally)
Lunch: Bologna sandwich
Potato chips Coke
Dinner: Chopped meat
Fried potatoes
Snacks: Crackers and peanut butter
Food allergies/intolerances/aversions: None
Previous nutrition therapy? Yes. If yes, when: 2 years ago when Pt Dx with Stage 3 chronic kidney disease. Where?
Reservation Health Service.
Current diet: Low simple sugar, 0.8 g protein/kg, 2–3 g Na
Food purchase/preparation: Self
Vit/min intake: None
Intake/Output
Date
3/5 0701–3/6 0700
3/6 0701–3/7 0700
Time
0701–
1501–
2301–
1500
2300
0700
0
50
Total intake 0
Daily
total
0701–
1501–
2301–
1500
2300
0700
0
50
NPO
NPO
NPO
NPO
50
0
50
0
0
0
0
(0)
(0.7)
(0)
(0.7)
(0)
(0)
(0)
(0)
Urine
0
100
0
100
200
800
0
1000
(mL/kg/hr)
(0)
(0.171)
0
(0.057)
(0.341)
(1.365)
(0)
(0.569)
Emesis
output
0
50
0
50
100
50
0
150
P.O.
Daily
total
I.V.
(mL/kg/hr)
I.V.
IN
piggyback
TPN
(mL/kg)
OUT
Other
Stool
31
Total output 0
150
0
150
300
850
0
1150
(2.0)
(0)
(2.0)
(4.1)
(11.6)
(0)
(15.7)
(mL/kg)
(0)
Net I/O
0
2100
0
2100
2300
2850
0
21150
Net since admission (3/5) 0
2100
2100
2100
2400
21250
21250
21250
Laboratory Results
Ref. Range
3/5
Sodium (mEq/L)
136–145
130 !
Potassium (mEq/L)
3.5–5.5
5.8 !
Chemistry
(Continued)
Laboratory Results (Continued)
Ref. Range
3/5
Chloride (mEq/L)
95–105
91 !
Carbon dioxide (CO2, mEq/L)
23–30
20 !
BUN (mg/dL)
8–18
69 !
Creatinine serum (mg/dL)
0.6–1.2
12.0 !
Glucose (mg/dL)
70–110
282 !
Phosphate, inorganic (mg/dL)
2.3–4.7
9.5 !
Magnesium (mg/dL)
1.8–3
2.9
Calcium (mg/dL)
9–11
8.2 !
Albumin (g/dL)
3.5–5
3.7
Prealbumin (mg/dL)
16–35
20
Alkaline phosphatase (U/L)
30–120
90
ALT (U/L)
4–36
26
AST (U/L)
0–35
28
Lactate dehydrogenase (U/L)
208–378
315
Cholesterol (mg/dL)
120–199
220 !
HDL-C (mg/dL)
.55 F,.45 M
50 !
LDL (mg/dL)
,130
135 !
LDL/HDL ratio
,3.22 F
2.7
,3.55 M
Triglycerides (mg/dL)
35–135 F
200 !
40–160 M
HbA1c (%)
3.9–5.2
8.9 !
Collection method
—
Random specimen
Color
—
Straw
Urinalysis
Appearance
—
Slightly
hazy
Specific gravity
1.003–1.030
1.025
pH
5–7
7.9 !
Protein (mg/dL)
Neg
21 !
WBCs (/HPF)
0–5
20 !
Case Questions
I.
Understanding the Disease and Pathophysiology
1.
Describe the physiological functions of the kidneys.
2.
What diseases/conditions can lead to chronic kidney disease (CKD)? Explain the relation- ship
between diabetes and CKD.
3.
Outline the stages of CKD, including the distinguishing signs and symptoms.
4.
From your reading of Mrs. Joaquin’s history and physical, what signs and symptoms did she have
that correlate with her chronic kidney disease?
5.
What are the treatment options for Stage 5 CKD? Explain the differences between hemodialysis
and peritoneal dialysis.
II. Understanding the Nutrition Therapy
6.
Explain the reasons for the following components of Mrs. Joaquin’s medical nutrition therapy:
Nutrition Therapy
Rationale
35 kcal/kg
1.2 g protein/kg
2gK
1 g phosphorus
2 g Na
1000 mL fluid 1 urine output
III. Nutrition Assessment
7.
Calculate and interpret Mrs. Joaquin’s BMI. How does edema affect your interpretation?
8.
What is edema-free weight? Calculate Mrs. Joaquin’s edema-free weight.
9.
10.
What are the energy requirements for CKD?
Calculate what Mrs. Joaquin’s energy needs will be once she begins hemodialysis.
11.
What will Mrs. Joaquin’s protein requirements be when she begins hemodialysis? What standard guidelines
have you used to make these recommendations?
12.
What are the considerations for differences in protein requirements among predialysis, hemodialysis, and
peritoneal dialysis patients?
13.
Mrs. Joaquin has a PO4 restriction. Why? What foods have the highest levels of phosphorus?
14.
Mrs. Joaquin tells you that one of her friends can drink only certain amounts of liquids and wants to know if
that is the case for her. What foods are considered to be fluids? What recommendations can you make for Mrs.
Joaquin? If a patient must follow a fluid restriction, what can be done to help reduce his or her thirst?
15.
Several biochemical indices are used to diagnose chronic kidney disease. One is glomerular filtration rate
(GFR). What does GFR measure? What is a normal GFR? Mrs. Joaquin’s GFR is 28 mL/min. Interpret her value.
16.
Evaluate Mrs. Joaquin’s chemistry report. What labs support the diagnosis of Stage 5 CKD?
17.
Which of Mrs. Joaquin’s other symptoms would you expect to begin to improve?
18.
Explain why the following medications were prescribed by completing the following table.
Medication
Capoten/ captopril
Erythropoietin
Sodium bicarbonate
Indications/Mechanism
Nutritional Concerns
Renal caps
Renvela
Hectorol
Glucophage
10. What health problems have been identified in the Pima Indians through epidemiological data?
Explain what is meant by the “thrifty gene” theory. Are the Pima at higher risk for complications of
diabetes? Explain.
IV. Nutrition Diagnosis
11. Choose two high-priority nutrition problems and complete a PES statement for each.
V. Nutrition Intervention
12. For each PES statement, establish an ideal goal (based on the signs and symptoms) and
appropriate intervention (based on the etiology).
13. Why is it recommended for patients to have at least 50% of their protein from sources that have
high biological value?
14. What resources would you use to teach Mrs. Joaquin about her diet?
15. Using Mrs. Joaquin’s typical intake and the prescribed diet, write a sample menu. Make sure you
can justify your changes and that it is consistent with her nutrition prescription.
Diet PTA
Breakfast:
Sample Menu
Cold cereal (¾ c unsweetened)
Bread (2 slices) or fried potatoes (1 medium potato)
1 fried egg (occasionally)
Lunch:
Bologna sandwich (2 slices white bread, 2
slices bologna, mustard)
Potato chips (1 oz)
1 can Coke
Dinner:
Chopped meat (3 oz beef)
Fried potatoes (1½ medium)
HS Snack:
Crackers (6 saltines) and peanut butter (2
tbsp)
16. After evaluating Mrs. Joaquin’s typical diet, what other recommendations can you
make?
17. Write an initial ADIME note for your consultation with Mrs. Joaquin.