Step 3: Implement

Interdisciplinary Team

When implementing your nutrition care plan, you may have to liaise with other members of the care team. This is particularly pertinent if a patient requires a fluid restriction or if they are starting or taking a phosphate binder.

  • Nephrologist: Doctors who have advanced training in treating kidney disease
  • Nurse Practitioner: A registered nurse with advanced education to be able to assess, diagnose, treat and monitor a wide range of health problems
  • Nephrology Nurse: A nurse with specialized experience in the care of patients with chronic kidney disease.
  • Social Worker: Provide counselling and identify sources of emotional support for patients and their families cope with kidney disease
  • Pharmacist: Review the patient’s medication orders for appropriateness and ensure that the right medication and the right dose is administered
  • Patient Care Technician and/or Renal Technologist: Responsible for the education, maintenance and cleaning of renal equipment, such as dialysis machines.


Liaising with Raymond’s Team

In Raymond’s case, you can liaise with:
  • The nurse practitioner and/or nephrologist about Raymond’s fluid restriction
  • The nephrologist, nurse practitioner, and/or nurse regarding the changes to Raymond’s diet order
  • Liaise with the nephrologist and pharmacist to start 1 tab calcium-based phosphate binder daily with dinner (his largest meal), since it is not within the RD scope of practice to prescribe phosphate binders


When implementing your plan, you will spend some time speaking with the patient about kidney disease and the dietary changes they may have to make. When providing education to patients try to:

  • Individualize the education as much as possible, based on their stage of kidney disease and labs. If the patient’s potassium and phosphorus is not elevated, then no K/PO4 intervention is required at that time, and you can continue to monitor
  • Find out if patient has had previous education: Ask the patient if any one else has talked to them about their diet and kidney disease. If the patient is followed by another renal dietitian, it might be worthwhile to reach out to them to gain additional information about the patient’s situation and provide a summary of your nutrition interventions while in hospital.
  • Focus on a few key messages: If the patient is newly diagnosed or doesn’t know much about kidney disease, try not to overwhelm them with too much information during your first couple of interactions

Think of some key messages you might want to speak to Raymond about when providing education as you implement the nutrition care plan.

Raymond’s Education – Key Messages

Before implementing the diet order, you need to meet with Raymond to go over the plan with him. In your meeting with him, you can explain the reasons for the dietary changes and what that means in terms of the types of foods he will be receiving while he is in the hospital. When you ask him if he has been told to make diet changes before, he tells you the only thing he remembers that his family doctor has told him many times to cut back on the amount of salt he is eating because of his history of high blood pressure.

You decide to talk to him about 3 key messages related to the changes to his diet:

  1. Your kidneys are not able to filter enough fluid and salt from your blood. So when you drink a lot of fluid and eat too much salt, the fluid builds up in your ankles, making them swollen. To try to reduce the swelling, you will get foods that are lower in salt and only get about 6 cups of fluid to drink in a day.
  2. Some foods, like processed meat, cheese, and milk contain higher amounts of phosphorus. You won’t get these foods very often on your tray at the hospital because your kidneys cannot process a large amount of phosphorus.
  3. Your kidneys are also not able to process high amounts of protein, which is why you may receive smaller portions of meat in your meals than you are used to having.

Practice explaining the three key messages in plain language.

Using analogies

It can also be helpful to use simple analogies. For example, kidneys are like oil filters in cars. In using this analogy to help educate a client about kidney disease, you could say:

“In our bodies, the kidneys’ role is to clean and filter our blood, kind of like how cars need filters to clean the oil that moves throughout the engine to keep it running. Sometimes when filters get old or they break they are not able to filter the oil properly. This is what happens when you have kidney disease since your kidneys can no longer clean the blood the way they used to, so we need to make some changes to ensure your body can still function.”

The hood of an old car is propped open, exposing the engine and its various parts.
Image by nastogadka via Pixabay

Supporting Change

Ongoing management of a chronic disease can lead to burnout, and making dietary changes may be difficult for some patients. To help support them in making these changes, you may want to try:

  • Motivational interviewing: collect their story, listen reflectively, collaborate rather than convince
  • setting: help to identify barriers to change as part of creating a nutrition care plan with the client
  • Referral to social worker: consider referring them to a social worker if they need someone to talk to about coping with the burden of managing a chronic disease

In Raymond’s case, he could set some SMART goals as part of his discharge plan on how he can reduce his sodium, protein, phosphorus and fluid intake once he returns home.

Think about some SMART goals that you could set in collaboration with Raymond.

Raymond’s SMART Goals

Using recommendations from the Ontario Renal Network Fact Sheets, once Raymond returns home, he can reduce his sodium, protein, phosphorus, and fluid intake by trying to:

  • Limit consumption of processed foods with phosphate additives and salt (like bacon, frozen french fries, and pop)
  • Choose more fresh, homemade, and unprocessed foods (like fresh or frozen vegetables and unprocessed meat, poultry, and fish)
  • Reduce the amount of meat, poultry, and fish consumed at each meal (like having 3 ounces of chicken breast instead of 8 ounces)
  • Drink a maximum of 6 cups of fluid per day, including coffee/tea, pop, water, milk, and anything that melts at room temperature

As a part of making the goals SMART, you can discuss with him when he plans on making these changes and come up with ways to support him if or when he encounters barriers.

Suggestions for Raymond’s Diet

This table shows what a typical day for Raymond could look like when making choices that help to reduce his sodium, protein, phosphorus, and fluid intake once he is discharged. The changes made are bolded in the “After” column.

Meal Before (Raymond’s diet recall) After (Diet suggestions)
Breakfast 3 eggs, 2 slices bacon, 2 whole wheat toast and 1 double double coffee Sandwich with 2 eggs, tomato, 2 whole wheat toast, and 1 coffee with milk and sugar
Lunch 12 inch assorted meat submarine w/ lettuce, tomato, olives, cheese, mayo and 1 large cola 12 inch tuna submarine w/ lettuce, tomato, cheese, mayo, and 1 medium sprite or ginger ale
Dinner Chicken breast (8 ounces), frozen french fries, peas and carrots and 1 can of cola Chicken breast (3 ounces), mashed or roast potatoes with herbs, peas and carrots, and 1 cup of water


Simulation Activity: Raymond

PART 3: IMPLEMENT COMPLETE. Pause to reflect on the implementation strategies discussed. When you’re ready, move on to Part 4: Evaluation.





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Preparation for Dietetic Practice Copyright © by Megan Omstead, RD, MPH is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.