Nutrition 453, Spring 2016 Renal Homework 25 points

Transcription

1 Last 4 digit of PSU ID#7027 Nutrition 453, Spring 2016 Renal Homework 25 points CASE STUDY: Mr. Sparrow s mother Pricilla turned 70 years old at the end of January. She has struggled with obesity, type II diabetes, hypertension, and hypercholesterolemia for the past 30 years. During a recent visit with her primary care provider, she was diagnosed with end-stage renal disease (ESRD). This is likely secondary to progression of her type II diabetes. Patient was diagnosed with ESRD during a recent visit with her PCP. She has started undergoing hemodialysis, 3 days per week and you have been called to consult on the case. Complete the Nutrition Care Process (ADIME). A: ASSESSMENT 70 year-old African American female. Primary Medical History: Type 2 DM, HTN, and Hypercholesterolemia; recently diagnosed with ESRD and has started hemodialysis Ht: 5 2 Wet weight: 84 kg Dry weight: 78 kg Urine output: 30 ml per day Labs: Creatinine (mg/dl; Pre-dialysis): 6.8 Fasting Glucose (mg/dl): 280 Phos (mg/dl): 7.2 HgA1c (%): 11 PTH intact (pg/ml): 310 Total Cholesterol (mg/dl): 240 Albumin (g/dl; bromcresol green): 3.5 BUN (mg/dl; pre-dialysis): 60 BUN (mg/dl; post-dialysis): 22 K+ (meq/l): 6.0 Ca+ (mg/dl): 8.0 Medications: Lisinopril, Lipitor, Insulin, PhosLo, Epogen, Nephrocaps Dietary Intake. Patient is a retired school teacher and prepares most of her own meals. Per her diet history, patient reports that she likes to consume a large glass of prune juice, a slice of white bread with chocolate-peanut butter, and an orange for breakfast. Priscilla consumes lunch at the local senior center consisting of cream-based soups and sandwiches on white bread. Sometimes she opts for the classic grilled cheese on white bread with creamy tomato soup. Fruit cocktail with cantaloupes and honey dew is provided. For snacks she enjoys dried fruits and nuts. Dinner

2 is her largest meal and is consumed around 7PM. She often makes instant rice, dried beans, and her favorite winter squash. Patient checks her glucose twice daily. She complains of difficulty keeping her blood sugar within normal parameters. She reports having a very high blood sugar upon waking in the morning ( mg/dl). Patient also loves dairy (especially ice cream or cheese and crackers at night). In her spare time, she watches The Hallmark Channel and receives very little physical activity. Her PCP provided her with nutrition education regarding a healthy renal diet. She doesn t feel the information was explained thoroughly and she is confused about how to modify her diet to meet her new requirements. Calculate the following for this patient using the tables in your lecture notes and the materials provided on ANGEL to guide your thinking. You also may find information in Pronsky that will be useful: 1. Estimated energy needs using her actual body weight (ABW) (1 pt.) a. Using lower-end of range: 27 kcal/kg BW because Pricilla is obese (BMI: 32.5); used dry weight 78 kg as ABW i. 27 kcal kg BW x 78 kg=2106 kcal round to nearest 50 kcal 2100 kcal ii. Answer: 2100 kcal iii. Citation for kcal/kg BW used: *Beto et al. J Acad Nutr Diet. 2014;114: Estimated protein needs using ABW (1 pt.) a. Used 1.1 g/kg BW to keep P as low as possible i. 1.1 g kg BW x 78 kg= 85.8 g PRO rounded 86 g PRO ii. Answer: 86 g PRO iii. Citation for g/kg BW PRO used: *Beto et al. J Acad Nutr Diet. 2014;114: b. At least 50% of the total PRO must be HBV: i. 86 x 0.5= 43 g HBV protein 1. ½ cup of milk is the most that is allowed, providing 4 g protein g HBV [prescribed]-4 g HBV from milk=39 g HBV left ii. 39 g HBV remaining/7 g protein/meat=5.57 meat exch 1. Rounded to the nearest exchange: 6 meat exchanges 2. 6 meat exchanges x 7 g protein=42 g protein iii. Check: 42 g (meat) + 4 g (milk)=46 g from HBV HBV/86 g total PRO=53% from HBV OK c. 86 g total PRO allowed 46 g HBV= 40 g PRO from other foods i. Starch has 2 g PRO: 10 starch x 2=20 g PRO ii. Veg has 2 g PRO: 10 veg x 2= 20 g PRO

3 d. Total PRO: milk+meat+starch+veg i. (4g) + (42g)+ (20g) + (20g)=86 g PRO good ii. 86 g PRO x 4 kcal/g=344 kcal e. 344/2100=16.38% - rounded 16% PRO in the diet 3. Estimated needs for: sodium, phosphorus, potassium, fluid; if you use BW to calculate any of these, use her actual body weight not her ideal body weight (1 pt.) a. Sodium: 2-3 g/d b. Phosphorus: <1200 mg/d c. Potassium: 2-4 g/d d. Fluid: 1000 ml + urine output 1000 ml + 30 ml 1030 ml e. Citation for chosen values: *Beto et al. J Acad Nutr Diet. 2014;114: a. Assess the patient s weight status (wet and dry weight). Review your notes so that you use these weights for the appropriate assessments! (2.5 pt) a. Dry weight status: i. Pricilla s BMI calculated with use of her actual, dry body weight (78 kg; lbs) is 32.5, indicating she can be appropriately classified as having class I obesity (Jensen et al. 2013). 1. BMI calculation work: a inches x 0.025=1.55 m b. 78 (dry, ABW)/( )=32.46 rounded BMI: Citation for Classification: Jensen et al AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults; A Report of the ACC/AHA Task Force on Practice Guidelines and TOS. Circulation. 2014;129(25 Suppl 2):S102-S138 b. Wet weight status: i. Wet weight: 84 kg (184.8 lb) 1. Reflects amount of water consumed between treatments 2. Used as an indication of dietary compliance 3. Basis: 2.2 lb=1 kg=~1 L of fluid. Pts are allowed ~1 L of fluid/d, and dialysis takes place ~ every 2 days=~2 L of fluid retained=~4-5 lb. between dialysis treatments (Corwin RL, Kidney (Renal) Disease, slide 47) ii. Dry weight: 78 kg (171.6 lb) 1. reflects actual body weight of patient iii (wet weight) (dry weight)=13.2 lb!! Patient gained 13.2 lb!! iv. Analysis: Patient is consuming too much fluid between hemodialysis visits; patient is not exhibiting dietary compliance because weight gain of

4 only 4-5 pounds is allowed between dialysis treatments (4-5 lb. would indicate dietary compliance) (Corwin RL, Kidney (Renal) Disease, slide 47). For this type of weight gain (+13.2 lb.) to occur in 2 days as a result of excess energy intake is not plausible; this patient is consuming too much fluid in between dialysis treatments. b. In addition, identify at least 7 additional nutritional problems from the information above. At least 3 of these should be dietary issues that need to be addressed immediately. Include encpt Diagnostic terminology for each problem that you list that is also included in the encpt. If you use the lab values as indicators of a problem, be sure to use the values for renal patients that are provided in the Krause s table that has been posted on ANGEL (these are often different from individuals without renal disease). (1.5 pts.) 7 Additional Problems: 1. Excessive fluid intake (NI-3.1) a. Indicated by: A weight gain of 13.2 lb. between hemodialysis visits. 2. Excessive sodium intake (NI ) a. Indicated by: Consumption of high-sodium foods such as peanut butter, soups, cheese, nuts, and instant rice; a weight gain 13.2 lb. between hemodialysis treatments could be a result of thirst triggered by frequent consumption of high sodium foods. 3. Excessive phosphorus intake (NI ) a. Indicated by: Lab values elevated serum P (of 7.2 mg/dl P; normal for dialysis patients according to Krause s Food and the Nutrition Care Process (2016)= 3-6 mg/dl P) and frequent consumption of high-phosphorus foods such as: chocolate peanut butter, cream-based soups, lunch meat, cheese, dried fruit, nuts, dried beans, winter squash, and ice cream. b. Citation: Mahan, Escott-Stump, and Raymond: Krause's Food and the Nutrition Care Process, 14th Edition, Elsevier Saunders, St. Louis, MO, Altered nutrition-related laboratory values: high calcium-phosphorus product (NC-2.2) a. Indicated by: Lab values Ca x P (8) x (7.2)=57.6 CaP product; this is above the dangerous cut point of CaP product of 55 (Corwin RL, Kidney (Renal) Disease, slide 52). 5. Excessive potassium intake (NI ) a. Indicated by: Lab values elevated serum K (of 6.0 meq/l K; normal for dialysis patients according to Krause s Food and the Nutrition Care Process (2016)= meq/l K) and frequent consumption of high-potassium foods such as: prune juice, oranges, honey dew, dried fruit, and winter squash.

5 b. Citation: Mahan, Escott-Stump, and Raymond: Krause's Food and the Nutrition Care Process, 14th Edition, Elsevier Saunders, St. Louis, MO, Altered nutrition-related laboratory values: low serum calcium (NC-2.2) a. Indicated by: Lab values serum Ca+ of 8.0 mg/dl; normal for dialysis patient s according to Krause s Food and the Nutrition Care Process= mg/dl) b. Citation: Mahan, Escott-Stump, and Raymond: Krause's Food and the Nutrition Care Process, 14th Edition, Elsevier Saunders, St. Louis, MO, Obese, Class I (NC-3.3.3) a. Indicated by: Dry weight assessment BMI of 32.5=classified as having Class I obesity by Jensen et al. (2013). b. Citation: Jensen et al AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults; A Report of the ACC/AHA Task Force on Practice Guidelines and TOS. Circulation. 2014;129(25 Suppl 2):S102- S138 D: DIAGNOSIS 5. a. Of the problems that you listed above in #4b, select two specific nutrition problems that need to be resolved or improved through treatment/nutrition intervention by a dietetics practitioner right away. Why did you select these two out of all of the problems that she has? (1 pt) a. Excessive fluid intake (NI-3.1) b. Excessive potassium intake (NI ) c. Reason for selection: I chose these two problems because they are the 2 that most severely affect two major areas of concern: 1.) The patient s comfort and 2.) the patient s survival. This patient s excessive fluid intake is severe, as seen by wet weight being >13 pounds more than her dry weight. This type of excess fluid would cause extreme discomfort for Pricilla during her hemodialysis treatments, and needs to be addressed right away. Excessive potassium intake is incredibly dangerous for patients with ESRD, as renal failure disallows the proper excretion of potassium, increasing risk for hyperkalemia. Hyperkalemia is incredibly dangerous as it can lead to heart failure (Corwin RL, Kidney (Renal) Disease, slide 46). Given Pricilla s affinity for high-potassium foods, immediate dietary intervention is necessary to address this risk for fatality. *Note: I see that Pricilla is on PhosLo a phosphate binder. It is likely that the reason for her elevated phosphate-related lab values could be a result of poor compliance to taking the PhosLo. This is the reason I did not choose excessive phosphorus intake as one of the two major problems.

6 b. Use this information to write 2 PES statements. Remember the interventions that you plan (see below) must be related to the nutrition etiology (E) not the medical diagnosis and not the P in your PES statement. Remember to use relevant encpt in your statements. (2 pts.) a. Excessive fluid intake (NI-3.1) related to thirst/water retention initiated by frequent consumption of food sources high in sodium such as peanut butter, soups, cheese, nuts, and instant rice as evidenced by a wet weight of lb., which is 13.2 lb. higher than the patient s actual (dry) body weight of lb. b. Excessive potassium intake (NI ) related to frequent consumption of food sources high in potassium such as prune juice, oranges, honey dew, dried fruit, and winter squash as evidenced by elevated serum potassium of 6.0 meq/l. I: INTERVENTION 6. Develop a sample menu using the 12-step renal exchange method that is in your renal disease lecture notes and that was reviewed in class. You MUST use the renal exchange method and clearly show each step as illustrated in your lecture notes to get credit. After analyzing the nutrient content of your sample menu for those nutrients that the renal exchanges cover (Protein/Na/K/Phos), you will need to use the diabetic exchanges to estimate CHO and FAT as you plan the menu. You will need to use SuperTracker (found on the ChooseMyPlate.gov website) or some other database for any other pertinent nutrients. Be sure to keep track of your portion sizes, especially for the fruits and veggies. An exchange in the renal exchanges may not equal an exchange in the diabetic exchanges, so be careful! You don t want to harm your patient because you recommended a portion that was too large and she ate too much potassium, or too small and she didn t get enough CHO to cover her insulin dose! See your lecture notes for examples. Note also that you may not be able to keep the phosphorus low and the protein high. If the dietary phosphorus is slightly over (~1200 mg), that s OK. (12 pts.) You MUST print out your database analysis to get full credit. Do NOT limit yourself to only the renal disease. The patient has many dietary problems that need to be included in your diet Rx and diet plan. You must consider her entire profile when planning the diet. Evaluate your sample menu by using a table similar to the one in Plan a Diet Using Exchanges lecture notes, and answer the compliance questions. NOTE!! Here is what must be in the Table: You are to evaluate the nutrients that are in the exchange lists using the EXCHANGE LISTS (renal and diabetes) based upon your calculations in the previous

7 steps, then put these numbers in the Table. You are ONLY to use SuperTracker for those nutrients that are NOT (!!!) in the exchange lists, then put those numbers in the Table. 1. Gather necessary information a. Summarized answer: Patient s dry weight is 78 kg. With a BMI of 32.5, patient is classified as having class I obesity (Jensen et al. 2013). She is on hemodialysis for ESRD treatment. Patient s urinary output/day is 30 ml/day. Co-existing conditions include obesity, type II diabetes, hypertension, and hypercholesterolemia. Medications include: Lisinopril (antihypertensive), Lipitor (antihyperlipidemic), PhosLo (phosphate binder), Epogen (recombinant human EPO), and Nephrocaps (multivitamin). i. BMI: 32.5 Class I Obesity; calculations done previously. ii. Type of treatment: Hemodialysis, several medications (listed above) iii. Urine output/day: 30 ml/d iv. Co-existing conditions: obesity, hypertension, T2DM, and hypercholesterolemia v. Citation for BMI classification: Jensen et al AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults; A Report of the ACC/AHA Task Force on Practice Guidelines and TOS. Circulation. 2014;129(25 Suppl 2):S102-S Determine total energy needs/day (same as above calculations) a. Using lower-end of range: 27 kcal/kg BW because Pricilla is obese (BMI: 32.5); used dry weight 78 kg as ABW i. 27 kcal kg BW x 78 kg=2106 kcal round to nearest 50 kcal 2100 kcal ii. Answer: 2100 kcal b. Source for kcal/kg BW value chosen: Beto et al. J Acad Nutr Diet. 2014;114: Calculate protein needs (same as above calculations) a. Used 1.1 g/kg BW to keep P as low as possible i. 1.1 g kg BW x 78 kg= 85.8 g PRO rounded 86 g PRO ii. Answer: 86 g PRO iii. Source for g PRO/kg BW chosen: Beto et al. J Acad Nutr Diet. 2014;114: s b. At least 50% of the total PRO must be HBV: i. 86 x 0.5= 43 g HBV protein

8 1. ½ cup of milk is the most that is allowed, providing 4 g protein g HBV [prescribed]-4 g HBV from milk=39 g HBV left ii. 39 g HBV remaining/7 g protein/meat=5.57 meat exch 1. Rounded to the nearest exchange: meat exchanges 2. 6 meat exchanges x 7 g protein=42 g protein iii. Check: 42 g (meat) + 4 g (milk)=46 g from HBV HBV/86 g total PRO=53% from HBV OK c. 86 g total PRO allowed 46 g HBV= 40 g PRO from other foods i. Starch has 2 g PRO: 10 starch x 2=20 g PRO ii. Veg has 2 g PRO: 10 veg x 2= 20 g PRO d. Total PRO: milk+meat+starch+veg i. (4g) + (42g)+ (20g) + (20g)=86 g PRO good ii. 86 g PRO x 4 kcal/g=344 kcal e. 344/2100=16% PRO in the diet 4. Calculate fat - % will vary depending on comorbid conditions a. Total fat: i. 30% of kcals from fat ii..3 x 2100=630 kcals from fat/(9 g/kcal)=70 g fat b. SFA, PUFA, MUFA i. 7% SFA (.07x2100kcal=147 kcal/9 kcal/g=16 g SFA) ii. 8% PUFA (.08x2100kcal=168 kcal/9kcal/g=19 g PUFA) iii. 15% MUFA (.15x2100=315 kcal/9=35 g MUFA) 1. (7+8+15)=30% - good g + 19 g + 35 g=70 g - good 5. Calculate CHO - % will vary depending on comorbid conditions If diabetes incorporate CHO Exchanges here a. 16% (PRO) + 30% (Fat)=46% b. 100%-46% (PRO + FAT)= 54% of energy from CHO. i..54 x 2100=1134 kcals from CHO/(4 g/kcal)=284 g CHO c. Is this within the levels recommended for DM? YES! (range is 45-65%) 6. Check ensure all macronutrients add up to 100% a. 16% (PRO) + 30% (Fat) + 54% (CHO)=100% 7. Determine fluid, sodium, potassium and phosphorus allowances a. Fluid: 1030 ml/d ( [urine output])=1030 ml/d b. Sodium: 2-3 g/d\ c. Potassium: 2-4 g g/d d. Phosphorus: <1200 mg/day e. Source for chosen values: Beto et al. J Acad Nutr Diet. 2014;114:

9 8. Write the Rx. Then, distribute renal exchanges according to macronutrient, fluid & micronutrient goals enter in table format Rx: 2100 kcal, 16% PRO (86g), with >50% of protein from HBV, 30% fat (70 g), 7% SFA (16 g), 8% PUFA (19 g), 15% MUFA (35 g), 54% CHO (284 g), 2-3 g Na, 2-4 g K +, <1200 mg P, 1030 ml fluid, 1200 mg Ca 2+ Table: Renal Exch PRO (g) Fat (g) CHO (g) Fluid Na + K + P (ml) 1/2 C milk (2%) med-fat meat 2 lean meat med-k+ veg 4 low-k+ veg starch Total so far Maximum of 4000 mg K+ allowed 2315 mg K+ so far=1685 mg left to use 2 med K+ fruit Total so far Goal g 2-4 g 1200 max What is left? OK high kcal CHO 5 fat Water Salt Choices Grand Total: OK! 2000 OK! 2725 OK! 1120 OK!

10 MACRO PRO(g) Fat (g) CHO (g) Fluid Na+ K+ P CHECK (ml) Grand Total: Time factor Kcal total: TO- TAL: 2062 % (divide totals by 2062) 16.7% within 1-2%...OK! 28.8 % Within 1-2% Ok! 54.5% Within 1-2%...OK! Ok! Within 50 kcal! 100% OK! HBV (MILK + MEAT) 46 x 4=184 kcal (pro kcal)/344 (total pro kcal)=53.5% OK! PRO g/kg g PRO=86 Kg=78 86/78=1.1 g/kg OK! 9. Develop sample menu, divided into the different eating episodes, making sure to distribute CHO appropriately if necessary. Breakfast Renal Exch PRO (g) CHO (g) FAT (g) FLUID (ml) Na K P 2 slices white bread 1 egg, scrambled 1 tsp olive oil (for cooking egg) 2 tsp stick butter ½ C apple juice Midmorning snack 2 starch meat/1 med-fat PRO diab fat fat med K+ fruit Renal Exch PRO (g) CHO (g) FAT (g) FLUID (ml) Na K P

11 ½ C milk (2%) ¾ C cereal, ready-toeat Lunch ½ C fruit cocktail 2 oz. deli-style turkey 2 slices white bread 1 tsp mayonnaise 4 tsp mustard 1 C lettuce (on sandwich) ½ C green beans, cooked 1 C spinach, raw 2 tsp salad dressing, mayonnaise type ½ oz pickle 1 milk/dairy; 0.75 milk diab starch Renal Exch PRO (g) CHO (g) FAT (g) FLUID (ml) Na K P 1 med K+ fruit meat/ lean PRO diab. 2 starch fat salt choice 1 low K+ veg; free diab. 1 low K+ veg (free diab.) med K+ veg; 1 veg diab fat salt

12 1 C lemonade Mid-afternoon snack 6 graham cracker squares ¾ C water Dinner 3 oz. pork cutlet ½ C Instant rice 2 C summer squash, cooked 1 C green beans, cooked 1 small dinner roll 1 C lemonade Evening Snack 3 oz. juice bar ¾ oz Pretzels, unsalted TO- TALS: 1 high kcal CHO Renal Exch PRO (g) CHO (g) FAT (g) FLUID (ml) Na K 2 starch Free Renal Exch 3 meat/3 med-fat PRO diab. 1 starch/ 1.5 starch diab 4 medium K+ veg 2 low K+ veg PRO (g) CHO (g) FAT (g) FLUID (ml) Na K P P starch high kcal CHO Renal Exch PRO (g) CHO (g) FAT (g) FLUID (ml) Na K 1 high kcal CHO 1 starch g PRO g CHO 66.5 g FAT 990 ml FLUID 2000 mg Na 2725 mg K P 1120 mg P

13 Time factor: Total Kcals: % (divide totals by ) total kcal 16.7%...OK! within 1-2% 54.2%...OK! within 1-2% 29.1%...OK! within 1-2% OK! Within 50 kcal of Rx (2100) 100% OK! HBV (MILK + MEAT) 46x4=184 kcal; 184 kcal (PRO KCAL)/344 (TOTAL PRO KCAL)=53.5% HBV OK! Pro g/kg g PRO=86 Kg=78 86/78=1.1 g/kg OK! 10. Analyze macro & micronutrients & fluids in table format. Use the exchange lists for CHO, PRO, Fat, Na, K, P. Don t forget the fluid! Use a diet analysis program to analyze anything in your Rx that is not covered by the exchange lists. Macronutrient & Micronutrients from Exchanges Analysis: Nutrient Goal (Rx) Amount in Sample Diet: Check: Kcal OK Within 50 kcal PRO 16% (86 g) 16.7% (86 g) OK Within 1-2%x HBV >50% 53.5% OK FAT 30% (70 g) 29.1% (66.5 g) OK Within 1-2 % CHO 54% (284 g) 54.2% (278.5 g) OK Within 1-2% Na 2-3 g 2 g OK K 2-4 g 2725 OK P <1200 mg 1120 mg OK Fluid 1030 ml 990 ml OK Micronutrient Analysis (nutrients in Rx but not included in exchange lists): *The SuperTracker document showing proof of this is attached*: Nutrient Goal (Rx) Diet Plan Check: SFA 7% (16 g) 9% A little high PUFA 8% (19 g) 6% A little low

14 MUFA 15% (35 g) 9% Low Ca mg 796 mg Low 11. Summary tables MACRONUTRIENT & MICRONUTRIENT SUMMARY TABLE (Exchange List) Nutrient Goal Meal Plan Evaluation How to Fix Kcal OK Within 50 No problem kcal PRO 16% (86 g) 16.7% (86 g) OK Within 1- No problem 2%x HBV >50% 53.5% OK No problem FAT 30% (70 g) 29.1% (66.5 g) OK Within 1-2 No problem % CHO 54% (284 g) 54.2% (278.5 OK Within 1- No problem g) 2% Na 2-3 g 2 g OK No problem K 2-4 g 2725 OK No problem P <1200 mg 1120 mg OK No problem Fluid 1030 ml 990 ml OK; a little low No problem MICRONUTRIENT SUMMARY TABLE (SuperTracker) Nutrient Goal Meal Plan Evaluation How to Fix Problems SFA 7% 9% A little high Replace butter with margarine at breakfast Replace pork cutlet at dinner with a serving of fish or chicken breast PUFA 8% 6% A little low Replace butter with margarine at breakfast MUFA 15% 9% Low Replace mayonnaise-based salad dressing with vinegar and olive oil

15 Replace a salt choice with a renal exchange serving of olives Calcium 1200 mg 3171 mg Low Add a serving of cottage cheese Include another serving of milk since phosphorus was not over the 1200 mg limit with current diet plan 12. Compliance questions o If goals not met, why? Goal for MUFA was set very high at 15%, and Pricilla was not consuming a lot of sources of MUFA beforehand. Keeping her food preferences in mind, I did not incorporate a lot of sources of MUFAs into her diet. Calcium goal not met because calcium-rich food sources are also phosphorus-rich food sources, which need to be restricted in ESRD patients on hemodialysis. o Foods the patient likes? Some food the patient has mentioned to eating/liking are included in this diet plan. These include white bread at breakfast, sandwiches on white bread at lunch, fruit cocktail at lunch, and instant rice at dinner. Foods that had to be replaced due to high P/K + content were replaced in the diet plan with similar foods, assuming that the patient will be able to enjoy them just the same. These replacements include apple juice for prune juice at breakfast, regular butter for peanut butter at breakfast, and summer squash in lieu of winter squash. I also incorporated replacements for high-phosphorus snacks with similarly crunchy alternatives, such as: cereal instead of nuts and pretzels instead of crackers. o Why/why not? It was very hard to include almost all of the foods that Pricilla prefers because she likes all the foods that are high in phosphorus and potassium which are harmful for an ESRD patient on hemodialysis! Therefore, I did my best to include what foods she was already consuming that were low in P and K +, while replacing the others with foods that seemed similar. o Social environmental constraints? I don t think this sample diet plan poses a risk for social or environmental constraints. It is stated that the patient prepares many of her meals, and all of the foods listed for breakfast, dinner, and snacks are affordable and can be found in all grocery stores. For the lunch that Pricilla consumes at the local senior center, I am not sure if she has access to fresh, cooked vegetables like the green beans I included in her diet plan, but the rest of the

16 o foods listed should be available as she was consuming sandwiches on white bread before. Comply? As long as the patient knew the severity of continuing to consume the foods she is currently consuming, I think she would comply especially after the discomfort she would experience during water removal during hemodialysis. It might be difficult because she really seems to like high K fruits and vegetables (i.e. winter squash). However, knowledge of the severity of her condition paired with the intervention goal of removing only 4 of the 6 high K + foods/day would likely (and hopefully) result in Pricilla s compliance. 7. Write two intervention statements. Remember to use relevant encpt in your intervention statements including what the RD will do, and what the patient will do using the WRAP approach. Remember, what you write should be specific enough for another dietitian to use on follow-up, if necessary. (2 pts.) a. Intervention Statement #1: Excessive fluid intake (NI-3.1) i. Intervention (RD): RD will provide nutrition counseling to facilitate goal setting for the patient to decrease frequency of consumption of high-sodium foods by removal of high-sodium food preferences from the patient s diet and replacement with lower sodium options (C-2.2). ii. Goals (Pricilla): To decrease frequency of consumption of high-sodium foods, Pricilla will replace a bowl of soup for lunch at the senior center with fresh, cooked vegetables and/or a salad on 5 of the 7 days this week. b. Intervention Statement #2: Excessive potassium intake (NI ) i. Intervention (RD): RD will provide patient with nutrition counseling to facilitate goal setting to decrease frequency of consumption of high-potassium foods by providing a detailed diet plan that excludes specific patient food preferences and replacing them with similar, alternative foods lower in dietary potassium (C-2.2). ii. Goals (Pricilla): To decrease frequency of consumption of high-potassium foods, Pricilla will refrain from consuming 4 of the following 6 foods each day for the next week: prune juice, oranges, honey dew, dried fruit, and winter squash, by replacing them with foods from the sample meal plan provided to her by her dietitian.

17 M/E: MONITOR/EVALUATE 8. Based on your PES and intervention statements, how will you determine the degree to which progress is being made and goals or desired outcomes of nutrition care are being met? (1 pt.) I will determine the degree to which progress is being made by: 1.) Tracking Pricilla s serum K + through coordination with a physician. 2.) Continuing assessment of Pricilla s wet and dry weight during her visits for hemodialysis treatment to check for adherence to prescribed fluid and sodium intakes. 3.) Have Pricilla fill out a food diary during her week to bring back to a follow-up visit to see her adherence to the diet plan and dietary goals set in the intervention. 4.) Have Pricilla fill out a food frequency questionnaire one month after this initial visit to gather information on her frequency of consumption of high sodium/potassium foods.