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  1. 1. 1 Anna King CSU ID# 829672579 FSHN 450; Fall Semester 2014 Case Study VI: Hemodialysis & Renal Diet Calculation November 5, 2014 I have not given, received, or used any unauthorized assistance on this assignment. Anna King 11/5/2014
  2. 2. 2 In table format, evaluate the patient’s laboratory data compared to goals for dialysis patients. Value Patient’s Value Dialysis patient Goal Sodium 135 mEq/L 135-145 mEq/L Potassium 4.4 mEq/L 3.5-5.5 mEq/L Chloride 111 mEq/L 100-110mEq/L CO 2 15 mEq/L 22-25 mEq/L Calcium 7.5 mg/dl 8.5-10.5 mg/dl Phos 10.2 mg/dl 3-6 mg/dl BUN 108 mg/dl 50-100 mg/dl Creatinine 14.0 mg/dl >15 mg/dl Albumin 2.8 g/dl 3.5-5 g/dl Hemoglobin 8.3 g/dl 7.4-9.9 g/dl Hct 24.3% 35-47% Transferrin Sat 18% 15-50% MCV 70 fl 80-99 fl WBC 8.7 X 109 /L 5-10 x 109 /L Urine protein 320 mg/24 hr 3-6 g/24 hr What is the purpose of each medication which has been prescribed for the patient? List drug:nutrient (food:medication) interactions for each. Lasix: increases excretion of sodium, potassium, magnesium, and calcium in urine- natural licorice may counteract the drug; maintain diet high in these compounds (may need supplementation) Lisinopril: ACE inhibitor, increases serum potassium levels-monitor hydration and fluid intake as well as salt and potassium intake (may be sensitive to potassium levels)
  3. 3. 3 Metoprolol: 𝛽-Adrenergic antagonist masks sympathetic signs of hypoglycemia-may decrease insulin release (in response to hypoglycemia), watch BG levels Renvela: phosphate binder (controls phosphate levels)- be careful with calcium supplements to prevent secondary hyperparathyroidism Zemplar: helps absorb calcium and helps with secondary hyperthyroidism- problems if allergic to man-made vitamin D or if there are high levels of calcium in the blood EPO: attends to anemia in patients- monitor iron status in patient! Ferrlecit: helps with anemia- may cause hypotension, excessive iron, and benzyl alcohol toxicity What is secondary hyperparathyroidism and why is this patient at risk? What are the consequences and how is this managed medically? Nutritionally? Secondary hyperthyroidism is a result of kidney malfunction/failure. When the patient’s kidney cannot filter minerals (in the case of secondary hyperparathyroidism, calcium and phosphorous, specifically) out of the blood properly, their levels shoot out of proportion. Generally, in the body, low levels of phosphorous and calcium in the blood are ideal. In secondary hyperparathyroidism, serum calcium levels are low while serum phosphorous increases; this triggers the parathyroid hormone to increase, which then, in turn, increases reabsorption of calcium. Since calcium levels are already low, the body takes calcium from bones of the body; this also mobilizes phosphorous from the bone. Increased levels of calcium and phosphorous from the bone, now in the bloodstream don’t necessarily have anywhere to go, so they form crystals in the tissues of the body. The patient is at risk of secondary hyperparathyroidism because she is in Stage 5 (the final stage) of chronic kidney failure. This is irreversible and she has to depend on dialysis for the rest of her life. Since her kidney cannot filter minerals properly, she is definitively at risk for secondary hyperparathyroidism. This condition is managed medically by frequent hemodialysis and is managed nutritionally by controlling intake of calcium and phosphorous. Assess the patient’s Kcal, protein, Phos, K, Na, and fluid intake recommendations. Kcal: 2061 kcal (35 kcal/Kg IBW) IBW=105+(5 x 5)=130lbs=58.9Kg
  4. 4. 4 Protein: 71g (1.2 g/Kg IBW) Phos: 0.8-1.2 g/day K: 2-3 g/day Na: 2-3 g/day Fluid: 750 ml (750-1000 ml/day urine output) Evaluate the patient’s current dietary intake including the following points: How does CN’s current intake compare to these recommendations? Some of the patient’s food is high in phosphorous, which she should monitor more closely. Although adequate calcium intake is required, she should be more careful when consuming foods. Calculate a dietary pattern which would meet the recommendations for this patient and using foods create a sample one day diet. Use table format and the handouts provided in class. This part counts as your renal diet calculation in addition to your case study. Protein: 17% of Kcal= 350 Kcal Fat: <30% of Kcal= 618 Kcal Carbohydrate: 53% of Kcal= 1092 Kcal Carb Protein Fat Na (mg) K (mg) P (mg) 1 cup milk 6 4 - 60 190 115 Fruit- Low K: pineapple (½ cup) 15 - - 15 100 15 Fruit- Med K: apple (1) 15 - - 15 200 15 Fruit- High K: kiwi (1) 15 - - 15 350 15 Veg- Low K: corn (½ cup) 5 2 - 15 100 20 Veg- Med K: peppers (1) 5 2 - 15 200 20 Veg- High K: sweet yam (½ cup) 5 2 - 15 350 20 Bread 209 17.5 40 35 500 450 SF Meat - 60 29 75 75 65 Reg Fat - - - 10 10 5
  5. 5. 5 Totals: 1100+350+621=2061 Kcal/day (275x4) = 1100 (87.5x4) = 350 (69x9 )=621 270 2075 740 Write two PES statements - one in the clinical and one in the behavioral domain and provide an intervention, monitoring, and evaluation plan for each. (1) Altered GI function [NC-1.4] related to abnormal absorption of calcium and phosphorous as evidence by kidney failure and hemodialysis. (2) Self monitoring deficit [NB-1.4] related to insufficient diet as evidence by 24 hour dietary intake log and medication needs. Intervention: (1) Take prescribed medications, monitor dietary choices (maintain low potassium and phosphorous levels in diet). (2) Watch diet! Educate patient on what to eat and what to avoid (avoid nuts and legumes, eat plenty of fruits and vegetables!) and show her how her diet and the foods she chooses affect her body physically. Monitoring/Evaluation: (1) Watch lab results on all values listed above, test urine samples to keep patient on track; hemodialysis every 2-3 days; monitor GI functioning. (2) . Monitor medication intake and make sure dosages and utilizations are correct.