1. Clinical Care Plan Presentation Fall 2014 By: Cassondra Hunter

2. Overview of Patient  Initials: J.P.  Gender: Male  Age: 25 years old  Admitted: 9/30/14

3. Psychosocial  African American  Lives at home with his family  Does all the cooking and grocery shopping for himself  Has a very positive, upbeat personality  He is very open to learning and receptive to new ideas regarding his diet

4. Physical Signs  Appeared thin  Skin was intact  No edema  Pt was wearing glasses

5. Anthropometric Data  Ht: 5’ 6”= 1.6764m  Wt: 123lbs = 56kg  BMI: (56kg)/(1.6764m) 2 = 20 ( normal )  IBW: 142 +/- 10% (128-1156lbs)  % IBW: 123lbs/142lbs = 87%  UBW: 123lbs; 100%UBW  Wt changes during hospital stay: 54.3kg, 53.8kg, 53.6kg, 56.2kg (pretty stable for a hemodialysis pt)

6. Medical History  Chief dx: Renal failure HTN, secondary to acute renal failure  PMHx: HIV  Was previously on dialysis for about 6 months, around one year ago

7. Medications  Metoprolol- 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

8. Acute Renal Failure  Characterized 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

9. Biochemical Data Lab TestNormal RangePt ValuesInterpretation Na136-145 mmol/L135L K serum3.5-5.1 mmol/L4.5WNL Cl98-107 mmol/L104WNL CO221-32 mmol/L23WNL Glucose74-100 mg/dL72L BUN7-18 mg/dL43H Creatinine0.6-1.3 mg/dL8H Phosphorus2.5-4.9 mg/dL1.9H Magnesium1.8-2.4 mg/dL1.5L Albuminfor renal pts want ~4-5g/dL 2.9L

10. 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

12. Nutrition History  Diet Order: 2gm K+, 2gm Phos, & Enlive 3x/day  NKA  Pt reports a “so, so” appetite, sometimes experiences nausea  Pt says it depends on the day whether he likes the Enlive supplements or not

13. Medical Nutrition Therapy  Increase protein needs d/t hemodialysis  Pt 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

14. 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

15. 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

16. Nutrition Care Process  Diagnosis:  Renal HTN  PES- Pt assessed with increased protein needs d/t hemodialysis treatments AEB low albumin lab of 2.9g/dL.

17. 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

18. 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

19. Monitoring & Evaluation  Nurses will record pts wt weekly in order to detect and avoid any significant wt loss  Nurses will also report pts consumption and tolerance of the Nepro supplement  Albumin 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

20. References  Pronsky, 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.