![\"Step](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/label_1-assess-1024x132.png\")
\r\n- \r\n \t
- Clinical Data<\/li>\r\n \t
- Anthropometric Data<\/li>\r\n \t
- Biochemical Data<\/li>\r\n \t
- Dietary Data and Social History<\/li>\r\n<\/ul>\r\n
\r\n Case Study: Meet Raymond<\/h2>\r\n<\/header>\r\n
\r\n\r\n\r\n[caption id=\"attachment_853\" align=\"alignnone\" width=\"1024\"]![\"Raymond](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/01\/Renal_Actor-1024x576.png\")
Raymond Zetner, your patient[\/caption]\r\n\r\n<\/div>\r\nIn the case study for this section, you are a Registered Dietitian in cardiology in-patient unit. The patient you are assessing is Raymond Zetner, a 72 year old man with chronic kidney disease (CKD). Raymond was admitted to the cardiology in-patient unit with congestive heart failure. He currently has stage 4 CKD, secondary to hypertension, and is experiencing ankle edema.\u00a0 He does not require dialysis at this time.\r\n\r\nHe has not yet been discharged from the hospital, and needs education before leaving.\r\n\r\n<\/div>\r\n<\/div>\r\nClinical Data<\/h1>\r\nWhen gathering clinical data, consider:\r\n
- \r\n \t
- Chronic Kidney Disease (CKD)<\/strong>: What stage? What is the cause?<\/li>\r\n \t
- Dialysis prescription: <\/strong>Are they on dialysis? If so, what type and what prescription?<\/li>\r\n \t
- Comorbidities: <\/strong>Ex. Diabetes, hypertension, cardiovascular disease, hyperlipidemia, metabolic syndrome<\/li>\r\n \t
- Fluid Status: <\/strong>How much urine are they producing? Are they retaining fluid? Edema present?<\/li>\r\n \t
- GI symptoms: <\/strong>Constipation, nausea, vomiting, poor appetite, meat aversion, taste changes are common symptoms of [pb_glossary id=\"1026\"]uremia[\/pb_glossary] in advanced CKD.<\/li>\r\n \t
- Medications: <\/strong>Replavite (Vit C & B complex, if on dialysis), Phosphate Binders (Tums\/Calcium Carbonate, Sevelamer, Lanthanum), Calcitriol (Active Vitamin D), Iron<\/li>\r\n<\/ul>\r\n
\r\n Raymond's Clinical Data<\/h2>\r\n<\/header>\r\n
\r\n- \r\n \t
- CKD: Stage 4 CKD, secondary to hypertension<\/li>\r\n \t
- Dialysis prescription: <\/strong>Does not yet require dialysis<\/li>\r\n \t
- Comorbidities: <\/strong>Hypertension; patient admitted to hospital with congestive heart failure<\/li>\r\n \t
- Fluid Status: <\/strong>Ankle edema present<\/li>\r\n \t
- Medications: <\/strong>Lasix 40 mg [pb_glossary id=\"945\"]BID[\/pb_glossary], Ramipril 20 mg [pb_glossary id=\"2302\"]OD[\/pb_glossary], Vitamin D 1000 IU OD, Omega-3 250 mg OD<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n
Anthropometric Data<\/h1>\r\nWhen gathering anthropometric data, you may retrieve this information from a variety of sources including the patient or their family members, the patient\u2019s chart or admission docket, or other healthcare professionals on the interdisciplinary team. Here you will want:\r\n
- \r\n \t
- Body weight<\/strong><\/li>\r\n \t
- Weight history: <\/strong>Usual body weight<\/li>\r\n \t
- Dry weight \/target weight \/ goal weight: <\/strong>Weight without any excess fluid, if on dialysis (edema-free body weight)<\/li>\r\n \t
- Inter-dialytic weight gains (if on hemodialysis): <\/strong>Fluid weight gained between dialysis sessions; this should be no more than 5% of body weight<\/li>\r\n \t
- Height<\/strong><\/li>\r\n \t
- BMI<\/strong><\/li>\r\n \t
- [pb_glossary id=\"1028\"]SGA[\/pb_glossary]<\/strong><\/li>\r\n<\/ul>\r\n
\r\n Raymond's Anthropometric Data<\/h2>\r\n<\/header>\r\n
\r\n- \r\n \t
- Weight = 65 kg<\/li>\r\n \t
- Weight Hx = 62 kg (usual body weight)<\/li>\r\n \t
- Height = 162 cm<\/li>\r\n \t
- BMI = 24.7 kg\/m2<\/sup><\/li>\r\n \t
- SGA = A (well-nourished)<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n
Biochemical Data<\/h1>\r\n
\r\n\r\nYou also want to gather the following labs included in the table below as part of your biochemical data. Keep in mind that the target ranges for patients with chronic kidney disease and those at end-stage renal disease (ESRD) may be different from the target ranges for the healthy population. Additionally, due to lack of consensus and evidence surrounding certain labs values, such as phosphorus and A1C, target ranges may vary based on the physician.\r\n\r\n<\/div>\r\n\r\n\r\n\r\n
\r\n \r\nBlood Work<\/th>\r\n CKD target range<\/th>\r\n ESRD target range<\/th>\r\n If high, think:<\/th>\r\n If low, think:<\/th>\r\n<\/tr>\r\n<\/thead>\r\n \r\n Creatinine<\/th>\r\n No target\r\n\r\nWill be elevated (>110 mmol\/L)<\/td>\r\n No target\r\n\r\nWill be elevated (>110 mmol\/L)<\/td>\r\n Kidney failure<\/td>\r\n Residual kidney function, overhydration<\/td>\r\n<\/tr>\r\n \r\n BUN \/ Urea<\/th>\r\n 2.5-8.0 mmol\/L\r\n\r\nUsually elevated (>8 mmol\/L)<\/td>\r\n 15-30 mmol\/L<\/td>\r\n Kidney Disease, poor dialysis clearance, high protein intake<\/td>\r\n Residual kidney function, frequent dialysis, low protein intake<\/td>\r\n<\/tr>\r\n \r\n Potassium<\/th>\r\n 3.5-5.0 mmol\/L<\/td>\r\n 3.5-5.5 mmol\/L<\/td>\r\n Intake of high potassium foods, K supplementation, K bath, K-sparing medications (ACE inhibitor or ARB)<\/td>\r\n Low intake, vomiting\/diarrhea<\/td>\r\n<\/tr>\r\n \r\n Phosphorus<\/th>\r\n 0.8-1.49 mmol\/L<\/td>\r\n 1.2-1.8 mmol\/L<\/td>\r\n Intake of high phosphorus foods, inadequate or not taking phosphate binders, high PTH, too much activated vitamin D<\/td>\r\n Low intake, excessive phosphate binders<\/td>\r\n<\/tr>\r\n \r\n Calcium<\/th>\r\n 2.1-2.6 mmol\/L<\/td>\r\n 2.1-2.6 mmol\/L<\/td>\r\n Meds (activated vitamin D, Calcium-based phosphate binders)<\/td>\r\n Poor nutritional status, over hydration<\/td>\r\n<\/tr>\r\n \r\n Albumin<\/th>\r\n 35-50 g\/L<\/td>\r\n >40 g\/L<\/td>\r\n Well-nourished \/ dehydration<\/td>\r\n Infection \/ illness \/ poor nutritional status \/ overhydration<\/td>\r\n<\/tr>\r\n \r\n A1c<\/th>\r\n <7.0 %<\/td>\r\n 7.1-8.5%<\/td>\r\n Uncontrolled diabetes<\/td>\r\n Hypoglycemia<\/td>\r\n<\/tr>\r\n \r\n Hemoglobin<\/th>\r\n 100-120 g\/L<\/td>\r\n 100-120 g\/L<\/td>\r\n High Erythropoietin stimulating agent (ESA) dose<\/td>\r\n High Erythropoietin stimulating agent (ESA) dose, Iron deficiency, GI Bleed\/blood loss<\/td>\r\n<\/tr>\r\n \r\n PTH<\/th>\r\n 3-12 pmol\/L<\/td>\r\n 14-65 pmol\/L<\/td>\r\n Hyperparathyroidism<\/td>\r\n Adynamic bone disease<\/td>\r\n<\/tr>\r\n \r\n Sodium<\/th>\r\n 135-145 mmol\/L<\/td>\r\n 135-145 mmol\/L<\/td>\r\n Dehydration, poor intake<\/td>\r\n Overhydration<\/td>\r\n<\/tr>\r\n \r\n Bicarbonate<\/th>\r\n 23-31 mmol\/L<\/td>\r\n 23-31 mmol\/L<\/td>\r\n Alkalosis<\/td>\r\n Metabolic acidosis, high protein intake<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n Interpreting Glomerular Filtration Rate<\/h2>\r\n<\/div>\r\n
\r\n\r\nThis table contains information that allows you to interpret a patient\u2019s Glomerular Filtration Rate (GFR), which estimates the percentage at which their kidney is functioning. Based on their stage of kidney disease, this table also describes what types of actions would be reasonable and the dietary implications.\r\n\r\n<\/div>\r\n\r\n\r\n
\r\n \r\nStage<\/th>\r\n Kidney Function (KF)<\/th>\r\n GFR<\/th>\r\n Action<\/th>\r\n Effect on Diet<\/th>\r\n<\/tr>\r\n<\/thead>\r\n \r\n N\/A<\/th>\r\n At increased risk<\/td>\r\n >90 with CKD risk factors<\/td>\r\n Screening, CKD reduction<\/td>\r\n Usually no effect on potassium (K) or phosphate (PO4<\/sub>). Sodium restriction, Avoid high protein intake >1.3 g\/kg\/day<\/td>\r\n<\/tr>\r\n \r\n I<\/th>\r\n Kidney damage with normal or \u2191 GFR<\/td>\r\n >90<\/td>\r\n Diagnosis and treatment of underlying condition, delay progression<\/td>\r\n Usually no effect on K\/PO4<\/sub>. Sodium restriction, Avoid high protein intake >1.3 g\/kg\/day<\/td>\r\n<\/tr>\r\n \r\n II<\/th>\r\n Mild \u2193 KF<\/td>\r\n 60-89<\/td>\r\n Estimating progression, delay progression<\/td>\r\n Usually no effect on K\/PO4<\/sub>. Sodium restriction, Avoid high protein intake >1.3 g\/kg\/day<\/td>\r\n<\/tr>\r\n \r\n III<\/th>\r\n Moderate \u2193 KF<\/td>\r\n 30-59<\/td>\r\n Evaluating and treating complications, delay progression<\/td>\r\n May have effect on K\/PO4<\/sub>. Sodium restriction, Avoid high protein intake >1.3 g\/kg\/day<\/td>\r\n<\/tr>\r\n \r\n IV<\/th>\r\n Severely \u2193 KF<\/td>\r\n 15-29<\/td>\r\n Preparing for kidney replacement therapy, treat complications, delay progression<\/td>\r\n Likely some effect on K\/PO4<\/sub>. Sodium restriction, Avoid high protein intake >1.3 g\/kg\/day<\/td>\r\n<\/tr>\r\n \r\n V<\/th>\r\n Kidney Failure (End Stage Renal Disease \u2013 ESRD)<\/td>\r\n < 15 or dialysis<\/td>\r\n Renal replacement therapy (dialysis\/transplant) if uremia is present<\/td>\r\n Likely some effect on K\/PO4<\/sub>. Sodium and fluid restriction. High protein diet required.<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n \r\n \r\n Raymond's Biochemical Data<\/h2>\r\n<\/header>\r\n
\r\n\r\nHere are the labs for Raymond which show that he has severely decreased renal function but does not yet require dialysis. Determine which lab values are [pb_glossary id=\"2390\"]WNL[\/pb_glossary] or are elevated. This information will be used when developing the nutrition care plan in the next section.\r\n\r\n\r\n
\r\n Lab Test<\/strong><\/th>\r\n Lab Result<\/th>\r\n Target Range<\/th>\r\n<\/tr>\r\n<\/thead>\r\n \r\n\r\n K (mmol\/L)<\/th>\r\n 4.7<\/td>\r\n 3.5 - 5.0<\/td>\r\n<\/tr>\r\n \r\n PO4 (mmol\/L)<\/th>\r\n 1.55<\/td>\r\n 0.8 - 1.45<\/td>\r\n<\/tr>\r\n \r\n Ca (mmol\/L)<\/th>\r\n 2.4<\/td>\r\n 2.1 - 2.6<\/td>\r\n<\/tr>\r\n \r\n Creat (mmol\/L)<\/th>\r\n 662<\/td>\r\n --<\/td>\r\n<\/tr>\r\n \r\n GFR (mL\/min)<\/th>\r\n 17<\/td>\r\n --<\/td>\r\n<\/tr>\r\n \r\n Urea (mmol\/L)<\/th>\r\n 39<\/td>\r\n 2.5 - 8.0<\/td>\r\n<\/tr>\r\n \r\n Alb (g\/L)<\/th>\r\n 43<\/td>\r\n 35 - 50<\/td>\r\n<\/tr>\r\n \r\n Na (mmol\/L)<\/th>\r\n 129<\/td>\r\n 135 - 145<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/div>\r\n<\/div>\r\n[h5p id=\"76\"]\r\n Dietary Data and Social History<\/h1>\r\nWhen gathering dietary and social history data, consider:\r\n
- \r\n \t
- Current Diet<\/strong>\r\n
- \r\n \t
- Diet order for inpatients<\/li>\r\n \t
- How much are they eating and drinking?<\/li>\r\n \t
- How is their appetite?<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
- Diet Hx<\/strong>\r\n
- \r\n \t
- [pb_glossary id=\"1644\"]FFQ[\/pb_glossary], 24 hour recall, 3-day food record (Note: A food frequency questionnaire might be useful if trying to determine a specific dietary cause of a high serum potassium or phosphorus)<\/li>\r\n \t
- Details on protein intake and fluid intake<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
- Eating behaviours at home<\/strong>\r\n
- \r\n \t
- How many meals per day?<\/li>\r\n \t
- Frequency of eating out?<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
- Factors affecting intake<\/strong>\r\n
- \r\n \t
- Social History: do they have a support system? Housing? Income?<\/li>\r\n \t
- Food access and preparation: who does cooking and grocery shopping?<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n
\r\n Raymond's Dietary Data<\/h2>\r\n<\/header>\r\n
\r\n- \r\n \t
- Current Diet\r\n
- \r\n \t
- Regular diet order<\/li>\r\n \t
- Fluid intake ~ 2 litres per day<\/li>\r\n \t
- Pt reports good appetite in hospital<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
- Eating behaviours at home\r\n
- \r\n \t
- Good appetite, eats 3 meals per day<\/li>\r\n \t
- Largest meal is dinner<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
- Factors affecting intake\r\n
- \r\n \t
- Lives alone<\/li>\r\n \t
- Full-time job as a lawyer<\/li>\r\n \t
- Eats out often<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
- Diet recall of typical day prior to admission:\r\n
- \r\n \t
- Breakfast: 3 eggs, 2 slices bacon, 2 whole wheat toast and 1 double double coffee<\/li>\r\n \t
- Lunch: 12 inch assorted meat submarine w\/ lettuce, tomato, olives, cheese, mayo and 1 large cola<\/li>\r\n \t
- Dinner: Chicken breast (8 ounces), frozen french fries, peas and carrots and 1 can of cola<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n\r\n\r\nPART 1: ASSESS COMPLETE. Pause to think about the assessment strategies discussed and data collected. When you\u2019re ready, move on to Part 2: Plan.\r\n\r\n<\/div>\r\n ","rendered":"\n
Page Contents<\/p>\n
- Current Diet\r\n
- SGA = A (well-nourished)<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n
- Weight history: <\/strong>Usual body weight<\/li>\r\n \t
- Comorbidities: <\/strong>Hypertension; patient admitted to hospital with congestive heart failure<\/li>\r\n \t
- Dialysis prescription: <\/strong>Are they on dialysis? If so, what type and what prescription?<\/li>\r\n \t
- Chronic Kidney Disease (CKD)<\/strong>: What stage? What is the cause?<\/li>\r\n \t