Clinical Care Plan Presentation Fall 2014

By: Cassondra Hunter

Overview of Patient Initials: J.P.Gender: MaleAge: 25 years oldAdmitted: 9/30/14

PsychosocialAfrican AmericanLives at home with his familyDoes all the cooking and grocery shopping for

himselfHas a very positive, upbeat personalityHe is very open to learning and receptive to

new ideas regarding his diet

Physical SignsAppeared thinSkin was intactNo edemaPt was wearing glasses

Anthropometric DataHt: 5’ 6”= 1.6764mWt: 123lbs = 56kg BMI: (56kg)/(1.6764m)2 = 20 (normal) IBW: 142 +/-10% (128-1156lbs)

% IBW: 123lbs/142lbs = 87%UBW: 123lbs; 100%UBWWt changes during hospital stay: 54.3kg,

53.8kg, 53.6kg, 56.2kg (pretty stable for a hemodialysis pt)

Medical HistoryChief dx: Renal failure HTN, secondary to acute

renal failurePMHx: HIVWas previously on dialysis for about 6 months,

around one year ago

MedicationsMetoprolol- antihypertensive

Take with food to increase absorption

Despmopressin- antihemorrhagic In FMI book says not to take this medication with

moderate to severe decrease in renal function

Phoslo- phosphate binder Take with food, avoid Ca supplement

Epivir & Prezista- HIV medications Take with food

Nifdipine- antihypertensive Low Na diet recommended

Acute Renal FailureCharacterized by a build up of urea and

nitrogen by-products in the blood This is measured with BUN lab values

Normal BUN level: 5-20mg/dl Elevated BUN indicated the kidney cannot clear

urea nitrogen from the blood The pts renal failure HTN may have lead to a

“leaky” glomerulus, which is why there has been a build up of toxins in the blood

Treatments could include CRRT, peritoneal dialysis or hemodialysis which remove the toxins from the pts blood

Biochemical DataLab Test Normal Range Pt Values Interpretation

Na 136-145 mmol/L

135 L

K serum 3.5-5.1 mmol/L 4.5 WNLCl 98-107 mmol/L 104 WNL

CO2 21-32 mmol/L 23 WNLGlucose 74-100 mg/dL 72 L

BUN 7-18 mg/dL 43 HCreatinine 0.6-1.3 mg/dL 8 H

Phosphorus 2.5-4.9 mg/dL 1.9 HMagnesium 1.8-2.4 mg/dL 1.5 L

Albumin for renal pts want ~4-5g/dL

2.9 L

What is hemodialysis?A treatment process that filters a pts blood and

removes all of the toxins Does the job of a healthy, properly functioning

kidney Uses diffusion and hydrostatic pressure

Dialysate is the solution used to replenish and diffuse certain things out of the blood Ex. If you wanted to supply a pt with Ca and bicarb,

the dialysate would have high amounts of each, that way, via diffusion, they would flow from high concentration in the dialysate to a low concentration in the pts blood. Conversely, it would have no urea, K+, or H2O to suck these out from the pts blood

Nutrition HistoryDiet Order: 2gm K+, 2gm Phos, & Enlive

3x/dayNKAPt reports a “so, so” appetite, sometimes

experiences nauseaPt says it depends on the day whether he likes

the Enlive supplements or not

Medical Nutrition Therapy Increase protein needs d/t hemodialysisPt will continue to follow his 2gm K+ diet, but

recommend reducing his phosphorus restriction even more from 2gm to 600mg, as well as putting him on a 2gm Na diet.

MSJ x 1.3 injury factor = 1,935kcals Protein- 1.6gm/kg

90gm Fluid- 25cc/kg = 1,400cc This pts fluid does not need to be restricted

because his I/Os are normal and don’t show that he is retaining fluids

Meal Plan Breakfast:

2 scrambled eggs cooked in 2 tbsp olive oil (2 medium fat meat + 2 fats)

1 slice whole wheat toast (1 starch)

1 tbsp low sodium peanut butter (1 high fat meat)

1c water Snack:

8oz Nepro Supplement (425kcal, 19.1g protein)

1oz unsalted saltines

Lunch: Stir fry: (2 starch, 2

vegetable, 2 lean meat) 2/3c white rice 1c steamed green

beans, cauliflower, & carrots

2oz chicken breast 1 pear (1 fruit) 1c water

Snack: 1 ¼ c watermelon (1 fruit) 1c water

Meal Plan (cont.) Dinner:

Chicken pasta dish: 1c pasta (3 starch) 3oz chicken breast (3

lean meat) 2tsp olive oil (2 fat) Cracked black pepper to

taste, sauté garlic in with the olive oil

1c carrots (1 vegetable) 1c Almond Breeze, vanilla

milk (low in phos) (1 dairy) 1c water

Snack: 1c grapes (1 fruit) 1c water

Fluid Intake: ~1400cc/day

Nutrients Provided: Na- 1,297mg K+- 2,130mg Phos- 900mg

Nutrition Care ProcessDiagnosis:

Renal HTN

PES- Pt assessed with increased protein needs d/t hemodialysis treatments AEB low albumin lab of 2.9g/dL.

Nutrition Care Process Intervention:

Pt will be fed three meals & three snacks a day following the 2gm Na, 2gm K+, 600mg Phosphorus diet Providing ~1900kcals, 90gm protein, and

1,400cc fluids A Nepro nutrition supplement will be provided

once per day, in place of the 3 Enlive supplements, as a mid morning snack Providing 425kcals & 19.1g protein per 8oz This change was discussed with the pt and he

was very open to the idea of trying the new supplement

Intervention (Cont.)Education:

Pt was educated about his newly increased protein needs d/t his hemodialysis treatments Pt was receptive to education and verbalized his

willingness to try Nepro in place of Enlive supplements

He was also reminded about avoiding high potassium and high phosphate foods

Pt was also able to name foods high in potassium that he already knew to avoid

Monitoring & EvaluationNurses will record pts wt weekly in order to

detect and avoid any significant wt lossNurses will also report pts consumption and

tolerance of the Nepro supplementAlbumin labs will be requested by F/U to see if

the Nepro supplement provided once per day is sufficient to help the pt meet his increased protein needs

Goal: Pt will consume 75-100% of his energy requirements and meet his protein requirements each day with the help of the supplement Nepro

ReferencesPronsky, Zaneta M., and Jeanne P. Crowe. Food

Medication Interactions. Birchrunville, Penn.: Food-Medication Interactions, 2010. Print.

Mahan, L. Kathleen., and Sylvia Escott-Stump. Krause's Food, Nutrition, & Diet Therapy. Philadelphia: Saunders, 2004. Print.

"Food Tracker." Super Tracker. USDA.gov. Retrieved from: https://www.supertracker.usda.gov/foodtracker.aspx Web. Oct 4, 2014

“Renal Nutrition Lecture Notes.” Kerstetter, Jane PhD.