NUT 116BLWinter 2012

FirstName Myi Last Name: BornsteIn-------'Section: I----

Case Study #4: Renal DiseaseDue at 10:00 am 3112/12

50 points

1. Please be concise and use only the space provided.2. Please cite sources as necessary.3. You may use your textbook, the pocket resource, and drugs.com.4. Case studies must be handwritten.

Part I: Initial PresentationChief Complaint: progressive anorexia; N/V; Skg weight gain in the past 10 days, edema,fatigue, worsening SOB with 2 pillow orthopnea, pruritus, and inability to urinate.

Patient History: JZ is a 42-year-old female. She was diagnosed with type 2 DM at age 22 buthas had poor adherence to treatment recommendation. She lives with her husband and children.Her husband also has type 2 diabetes. Her kidney function has been declining for the last S yearswith anemia, decreased GFR, and increased creatinine, phosphate and urea. JZ is being admittedin preparations for kidney replacement therapy.Onset: Dx: CKD 3 two years ago. Acute symptoms x 10 daysTx: prepare for kidney replacement therapy and nutrition consult.run .Gravida 2/para 2. Both infants weighed more than 11 lbs.Meds: Lasix, Metforrnin, Vasotec (has not refilled Vasotec prescription, inconsistent Metforrninand Lasix use)Family hx: Mother, father, one sister and two brothers have type 2 DM \

Physical Exam:General appearance: Overweight female, appears older than her age. Lethargic, c/o N/VVitals: Temp 98.6 F, BP 220/80 mm Hg, HR. 86 BPM, RR 25Extremities: muscle weakness, 3+ pitting edemaChest/lungs: Rhonchi with ralesHt: 5'2" wt: 158 lbs.

Nutrition History:General: Reports appetite is usually good but has been reduced recently because of the N/V.Attended a 4 week course through the hospital 8 years ago to learn type 2 DM management, butsaid she is so busy with her family that she doesn't have time to plan her meals.Usual dietary intake .Breakfast: 2 eggs, 3-com tortilla, ham or bacon. 8 oz. TampicoMorning snack: 4 orange juice, bananaLunch: 1 cup homemade chicken soup, 2 quesadillas 12 oz. TampicoAfternoon snack: 12 oz apple juice, 4 cookiesDinner: 6 oz. Rice, 6 oz. beans, 2 oz. cheese, 2 oz. salsa, 4 oz. chicken, 4 com tortillas 8 oz.whole milkEvening Snack: 8 oz. ice creamFood allergy/intolerance- NKFA's

Dx: Chronic kidney disease; hypertension; type 2 DM; hyperlipidemia

Tx Plan:Renal diet1.2 L FRNutrition Consult for renal diet educationCBC, blood chemistryVitamin/mineral supplementMetformin, Lasix, Vasotec, Phos Lo, Sodium Bicarbonate, EPO, Iron

,\-'?1. Briefly explain how type 2 DM can lead to chronic kidney disease. (3 points)

\)"G\bct\l ner\1\'tp.C\tI1~ \~ \nt mo~t commO\1 couce cf (1<.0, Peo\?lt wftt) -rIDrvI and TWMo.n C\t < \\ll¥tO S eC\ fl c K i e\peCiClII'l wnen 'o\C()c\ S'L.\qC\rKnot (cntrclled. Pro lonljed hyper-C)\,\t~Y(I\{'\ hem OM dama.qtS b\ood 'Jes~e\s \~ mt ~'dne"$ . 'E~€ntua\lY, q\cmercu I\'o..tt dtc,"\-yo~td.~~ t\r\e.. \I0h1bey of fUnl'DOn'V10 i'lephrcnf clcrre(t~e, ~fqney diS'ea,sc\~ \!\Lehl to beqm.

2. Although JZ c/o anorexia and weight loss, today's weight shows that she has actually \gained weight. Explain this discrepancy in subjective versus objective information. (1 ypoint) Sub}e.:t1Ve \nfcnY\o1fon gmte~ mer ih~ pt. has bcc:h IO~in5 wt. based.oD her-0\'"\111 percep1.1on of sympt1J\)1S such CIS Q~Qre~\C\ and N/V. But bewuse of ,herclecreQsed \(.\c\i1~~rvncj\Oh lC~D! ~nd \10.Ving edernq I the pt., Will be C\ heC\vl er wr.·V'4h.tO'rie~~htc\ \f) person. lrI~S is ~nc: obJeLnye: dClm 1t\CIt WIll inc..\ude the. w0ter- ,wel~\'tt tnat tile pt. mu~ 11Mbt intludlOg in her ~'1'mp11lm~ahd bWtl ciNah/SIS of herwt-. V'iater werght r etermcn I or edemct~\\\(\uCler ptlS d,"fn(urty U~irtCA1lt1g and QI1Y elcr:trDi'lte

3. Which foods in her usual diet are contributing most to (2 points): lh1bcHOhCCS.a) Phosphorous levels:

hC\ffi/bC\Con) b\:On~;icco-ecm f Y'4ho\e md\(., cheese

Laboratory:GFRBUNSerum creatinineCreatinine clearanceSerum sodiumSerum potassiumSerum albuminHgbHctSennn transferrinBPProteinuriaUrine pHSerum phosphorus

! /PT.HSerum alkaline phosphataseBlood HC03-

Urine volume

\ \loBLn~tes

15 mL/min90 mg/dL14 mg/dL17.0 mLimin142 mEq/L5.7 mEq/L2.8 g/dL11.5 g/dL28%155 mg/dL1601100, standing, right armNegative7.315.0 mg/dL100 pg/mL180 unitslL14.8 mEqlL450-mL/24 h

b) Potassium levels:

or~ngc J\,t\ce I iQlYlpfcO, bC\nCH1C1, SC\\S'C\ I wh()\e m{lI~ I Ice ered m

4. Explain the rationale for the following interventions: (4 points) \a) Phosphate binder ..f'

P~i)Srnate binderS V'411i dc:n{"cIse th e (1\')')OIJ\1T of phospt)(lte C\bS\Jrbed In the (11

i\'£1(i to .pre'J€nt h'lperphosphG\1tinlc\. V'Jith hiCjh leveis of p\t)Qspha'tE', (q IS p~lI~dfroWl ,\X\e bOne / \'Y)G\~i\'\<j tl'lem by\ttk (0 Sieopen \C1). Phc~p\1Cltc bihder.s prevcrrre:\t'lGlied PIli G\nc;\·therefore pre'Jem-s bone c\i~eC\sc and soft '"tf.ssue COltfffc(,rtllwl.

b) Calcium supplement ~ t(L\)'V't ei\ \t\[cl,s C\c.compCl~~ CKD becC\use of C\\tercmo\1S In Vit D. lY\etqbolt'Si'Y)(!ha~/ijy

to o.cl1ViAle ,Nt 0 III tt\e \L1~ne\(5), ~ccreC\~cd absorption of (a from the gu~ L\hd clev~tedpnospht>rus. ca supph:-yY1cntcrtlol'l \S nrokd because ClI-rlc.h feeds s\1ouldn'+ be-eatenSn)l~ tr\q .a\so lcntV\\n hfqh \t'4e\s of p04. Co 5ufP\ememat(o'f) mC\~ avoid secoodClt-vh'lpet'pC\\'O\tn'lYO\'clrswl, r.enal o~eod~~tmph~ one cardfO!/e~troS\Leie1Z\1 colo'ficcmOt\. Tl\~e ~I')

c) Iron and EPO , .' , emptY srcmach.e.~D pb. don.T s'/ntl1~s\1..e,EdtYll\Jcrte C\mo\)r\t2> of erythrapt;\etln so -there ,'s Q deci'eC\sem 12.\3G proctu.c:non I \tljb (And re. 6ecause. erythropole.s \$ re<t\lWes f()c..YeQsec\ Fe demand lbot\! 'R- o.nd ~PO ~r~ g\~m iOge\t1er So .that the pt. c\{)Q,sO't cecome Clnemit, I\\.so f'o.twuse \~'S l,l,UQI\'l U\\~X\O\N\'\ if mt p\;. \\ ~cftc.\~.nt in eltn~\- 'Fe or EfO me~ (.\\-e bethC\I\le.n -To \flt~ea.se, (h \10\dlV\9 capaCltv\ WYlie'", WI\\ \1elp rnai\'\tl\\Y'\ ~, t \/

d) Vitamin supplement containing only water soluble vitamin ..r 1.-~enc\\diets C\rt-na\lJrC\lI~ \\)\N WI "h,O -&c\ub\C Vito\\Ylif\,s, CI'()d d0ril'lg CKD, I1?-O.-·SOiubie.lJitvnmXls, hCNe. atteV'ro metub~\\S\Y\, \rn~(rerl S'lothes\~ cmd ~crvea~edd?SCl.rption~t\IS'o,ttlt're (lYe. iY\treo.scd \t>sses dU\'IV19 dld\'jS\5 ond from anoreXiC( ot)c\ ?~Ol dIetary \~'f:e.When \1C\\lIIICj CKD" V'Jctter -Sol l.\b\e Vit, -tncn-sha0ld be suppleme.l1ted Intlude. B-l/ciVlmtV)~

' .. ~l:t. G ~ eX ~\me,5. Explain tlie purpYJseof each of the following interventions, and list the data (laboratory

parameters, symptoms, etc.) indicating the need for treatment. (8 points)

\110Bl nOI e! }"-lW ~. 54\

\{\~ p~.'54\-543) I\\.Q BL

noies

l\I1V rq· 54 S ,\ \ lQBL i10teJ

NIP P9, 544,\llo Bl \1 ores

N ,x\'()f\(.\ \ ReVlC\ \Ofet-) -rw fCj.5341 S~\ ~IHoBl f\ote"s

Naliooa I Reoo \Ole+-) \110 8L

v\01€S

NQtiotlct\ Rene"Dle.t ) NIP Pc.!' S2S',

HI6BL Ylo'tes

Nat\O\')Q I RenalDiet) Nlf' PC}·

5~- 5'41 \\(QBlnot~-s )

lr1-a) Protein restriction Whe\'i tne v-idney \coses ItS fUnc\Hm d'J \A\"\db\e.. 'rc p\'"Operhl fHter-. e'l-C.tss rro\t1V1 from '\\')e b\ooc\ $'0 ~~'in ton bui\d \.Ipl and c.\"ec\1€. nftYO<)cV\ W<.1Sre.

1Y1\'~CC\\'\ 'be CI~o\ded 0: decreased by Y"es1ncnnCj 'Jr()'1~in \t)ine-diet, and merefor.e-pL\'\\In':),\ts~ STress on m~\<.\?"'t'l-S. We C\\Sc Want 10 1\\lninll'ZC Cfl.otern\CI, cmd.uYl?IYl\C\.

, \'<ec'd Inta\Lt s\')Q\lld ~ limITed io O.~ - \,0 3/K9 I BW, cneclcthc f'tl\cW1fl5 \obs ~BUN, serum CII serum Qlb.) ~fi<. tL

b) Phosphorus restrictio~. &CClUS e.. of detv-eased renal N<.re1l0n of POt! ond int\'e(1scr:\..p\lo~~l)nAS reabS()\,ynon I serum \>ncs\?\t)oyI..lS iC'ltyms~ 'to \eVe\s that if\c.reQses PI H.·ltI(~ (e\\'l \rod '\0 bone d~seose (\11(1det\'euse.o mlne.r-ctlizailOii. 'Restrict f'04 TO preventml') from ~O~~en\f'<3' tv1Cl1f\1}y'" s~(um (Q I serum p\1CiphCnlS clnd PTlt S'IlfI\1tcmsW\(\'1 w't\ud~ C\ c~.Ye.QS~ in 'oJne tl~sue C\\lcAtneref'ore \ower dC\'lSI1y ~\IeJ, FesiYlc:.trOLl Ii'lta\l-e 10 16- \2 ~<3/ kq IBW 0 "r-\ IJz.

c) ~otassium restriction 1h~ reu$onic rcstnc.t kt, ro 'tile die+ i'~UJUC\\I~ o1'\l~ if ferUM IdIS €\e"V'crted. Kt snl)u\d be reS\Yfcted io pre\fe\'if" cardIac, StraHl. liiCJn \eve\s ~ ~t ffi(.\\LeSthe. heart '1'10(\'- harder- i \I\I'r\\c\1 c.C\\1tYlen lead to athero~cle(()sis , Ar;" flfR dccil'YlCS, 'rne,e't.(,~eh~\'\rcxte of Kt i,ncreoses IblAt ·t\i i~ tempe\') SC(tcyy mechC\I'HS'I1). cloesn' ,t laSt \l)119\\jlh'\ tne. G\~l\)Wlu\nilon ,of Kt So -this \et\.ds Toh'lperKole\Y\\'C\ ~ it fssuCjqe~ted To\ndlvIGh,lalrre. \<t restridloY) per lab'Va\L\eS. e-hec.k tV\e f1JI\CiW\V}Q \G\bs" serum "*

?feVe(lt- Cl.N'hyl1'\Mw0 ]. ?-r z.,d) Fluid and/or sodium restriction -me n~o&cn -to Yestntt' flu I'd o.nd NG~ ISto pYe\lent" hi~h

\?V o.nd.W\~'V)t(\'\'\ flu\d b1\~lJCe. If 1h~ ~c\n~~s Oren'-t TIJrcticnm9 ~rcverb(i -mey Wn\IItt be O\'o\e to fmer \'\.2-0 cxnd NC\; SI) wa.tn tetel'lt\of\ \5 \,v-t\~ (edema) I \~Y'ilh,ttH~Cl\n \to.c\ to ni~h £'P. flu\'d \Y\iZ',?-e. \s 'oes-\. cont\'o\\ed '0'1 \iffi~t\n<j ~\e'\ary Net IlylG\¥-e.R~stntt "-1l\ '\0 1.-3 13/do.'J or \X\O\\I(duc.\\17e "'.20 and NG\ \'(\tz.\\Lt bc1sec\ onC\ppro\J'(\(~te "~dyct\lon ~-wtus. \\'\cnrtl)y t)Pj s.e\'U'({\ sodium I vrine c\JjpU't I ecleT1lC\

®

6. Complete a SOAP note for JZ at this point in time. (18 points) As part of your "plan"create an appropriate and a well-balanced Renal Diet (based on yourrecommendations) that JZ can follow at home. Use the attached renal diet pattern ~/~document. (8 points) . _ _

rc:1 • H. \5 42 '/Of . ()K\c\Y'\ey h\Oct1~nil1~ ~ee\iV1i\1~ over past 5 ~caYS .8J . Pt 'OJ.. \l\JitVl T2Dl'i\ <."fit Ol)e 22 (And \'j~s f~mi 1,,/ItA Df T2.DM ., p~.siates 'J \9 wt· 9QI\') ~ ~$t \0 davs

: .. re'tl 0 \1\-, \')'i w\-\-n C~D 3 'fears u<j0• r~·(/D. \tt~ayq\G, N('4 ~:nlJd ~~ \1; W()~~n"n9 8~.\S V\'~'par\''\<1'fe, ¥-\c\my y-ep\uc~mtnt~>\'{;jfY'~V1',has \f\,()~~\~1l110;J~~~ctnc~nto ,2DM Jset Yec)aS .Fr. V~: (;\(\)/ \tlN/\2.\)\'v\ hf~etll~\c\em~• Pt . nus \h V\ ~tor, -S1/1)t.-f

lQJ ~t\tnro{X?f(\t\r\k& .1:-~]mcrttd· NeedV \)lewry RtwH0'" \..ab5 "M', i5"1.scm \I kc.~\~ \lso'{WI Kec\!: 2r:)lo3Kwl ·1YH~·ftl\lb'v~~\abSc\\'-el()w; ~FR(lsmL/mill~c.r,w; ll. co I'-~ pro: S5 -10 <} (9:>/. IH3v) pro: \()2 9) Cre-~hnIl1e. Clearance. (n I\1LjrCIin)) scrLl\rl

flu(c\: C\SO - 1200 rnl, f\~id: NjA ~\bu\'Yl\n (2.'6 9/cll), HC:t(2~I,), -transferrin\7Ynl~~~,q ~/m2 NG\', 1ooo-30CO m'j NG\: 2~6(om~J (\55 m~ldl) I \Anne pti (7.~1), PTH(lOO P3imYI\Y1Y\J; ':)0 ~9 Yho(: sso mg rhos', 1lOCo I. S Wl5 biooo \-\(03- V4. <c \oE~/L) urine vel.1·IB~·· 14?doi, K: 2COO rn5 K \ 2(P'lO hJ9 (450 mt,/24 It) , ,\V\eo/ 14-.fIcIn tH'\Sis-t& of Current W Plan " Pi. rollc\I\J(n~ l~e follow1nq labs are n,!\)" BUN (CJO 1'03/cAL),

· tGI\LiY¥3 n"Iclfor\'Ylin,L.o.si'1., ~asote() re,1I9\,die+-With \.2 L f-R 9'1'OCI BP(llcO(IOO)1 seYIjrf) a\\!allne prosphcrtllSe, \?nos Lo SWI\)m 1?,fco\'b 't-PO Fe VI~/mlVlt:ral &\;Wpltmentmion l~'OO UYHtS/L)· 4. t'. (\\('II"CC.0.. f--\<'A~ A\lttgler" Ni'flts.[[l PES: UndesipAb\e feci choices 'r{t foro and nL\tr(tion-relctteci \[\1owltdqe dcfitit- related 'to (~D £,1eb 24-!1Y

· '(e(~1\ irlto.\Le of l,Al9J recd ~\) \lD2l rec)ci prOf 2Iq·/ reed Phos anc\ loS! rec.'d K, OIbnonJlal \C\b ValUeJ rai0relctte~ to \1utnentS ((WO, PTHi glAN i BY i \tc,+) GW\Oprejt\1ce of t'dem~l/ 1

'P\, \5 u~ne\'\\h( ticetdn1g e-S1imated \')rois \~ the fOl\()WlflC\ \'\L\tr(e\1t~:,\(cal"prD, P,\1QSI K andll'lLei'lt f1u(d~ ,-1'+, wcu\c\ benent frem ~ new clIft Ri of: 1150 Kcol, 5'5-10'3 protein (V'4\t~ S) /, HB'v) i qS(J -\200 IY\L flUid

~emi'(,""on, \000- oCCO ffi'j NC\, 8SD ttlc) wcs and 2iXD mlj ~tasSiu\'V\({O\'i!\ Ie, \\tfl'ocif{t\ fiis)S'6.• N~W diet R'#..foll()WS ctl®rv <jL\l'delrnes for a HO dlt1, .

I 'Abi1\)nna\ \Q'o ~(.\\ue.s \nc\ude''/ ~FRI tr cieircnce, "'Ib,) transferrin Ivnhe.\,i-\ PTH,o\ood IKO£, OV'int veL} BUNj Bfc S~(IJY\dory p\1)b\ems \l)c\ude vlAnUlV"ltYb\lect UDm I sev€,e edet¥'lc\., C\I 0 (c.tm,,\lrotfen of C~D) I h1embohc. ccrdoxis,

In) due to e\e\Jaied BP (Singe \I) I dt\1~drcrtlo\11 rt· fOI\()Wirt9 !lied plan (inuecued 'wof Medj) and no time to piCln m.t1lsog~\l\i\" hns tit t>f 12DM i 'WYliCh tClo\d be ~teiitj'G\1 prob lem when foH()WI'nCj t'leW dle-t- R¥D Pi. should b~ cautious {}f drug-oru(j imtrGu:ll'DI1S bctwte\1 Laslx and Va.sotec.y'"• \ fD\"~'eepct<:11tra\ tt>X'\,,\,\icH"\ce problems bemuse.. pt. pY(:''i,'o\JSly had peer oc\herC1nceto diet plG\\'i for ,20M

, a,nc\ l\'\C.ohslstantl~ ice\( pyevl'ovs hi edlcC\"n'c)\1S i ~nd pt. c\()eSn'-\- seern educated, turren+i~, on Ci<.D/m~OG1I"'o mmim'rze (ovnph'(<<h'onsof (I<D b"ll-'roYlclin~ C\d~uate Kcal and pYO·To prevent mctlYlutri1iOi1 (And\>YeseYVe I'HAI:c.le. tnctS5 ond serum p(l)tQiY\~ I tr€.C\t abnormalities of vltc\lId l'Y\ineral absorptyo() o ndIAtlllurheY1 +0 pYtve.V1t f\Art\'1U' (j(O (()YY'lr1,catfons (C.VD I «neMIC! SItPT) I YV\iYlilY\i'le uremia and osteopeniaJ

cmd \')crmo\i~e bl()od hpicl.\,/ . ' 1-1/(,;,Reed: i) \\Hw c\\e+ Ki tf: 1150 \~.wl,135-10 'j pro(w1th Slrl, t\8'v) I '15L\-1'200 fflL fR \()O()-3COO me NQ SSG m9D d (' .,/ j J i\nos un 2.~ tn9 \ T, . fdu..cuh:,cn C\1'J2enJ '!1li'r2) V1. snt)v\c\ Keep furl \05 to \(.ee-p tra.(\(of C()\(\pilol1Cetc tenC\\ d\eV \)\'i'Y \S ~c:IQJ:-7 n~ 'f?) Rt,'e, \'to to ne\Jhr()iDqi~t it, 'oe<.Ci'(~t ed\l.((\tec\ ClY\rena\ re~\o.ce\'Y\entmer-Dpy/' \Le\.cd-e(~\tt,l'lou..\.('C\1 1(1

4) Refer ~\-, to LOt 1() help ({)ntro\ ,20M (SeccndoY\fi~S\.Ae)/

· t,,\/E 'j-tocc\ \(0), \a'b v(.\lu(\S(~fR, Cr c\eanmce, olb., trcIY\sferrin, unnc pM I PTH I bloed it({)3~1unne \/'0\\ BIJN,\?)P

1serum C\\\(a\me pho~pYldTI\Sel ele&roh/H\S; Her I BG, TAG) I ~ti~ht-(;t/wee\() I eclelY\C\ i qnd pt.

S'lffi~Thms (N/V I foti5ue, woo!t.ness i rhOnc.hi I s08, orthopneQ, prurl-n\~ r inabilr~J 10\JrivlCIte)F/ \J~. 3 do".s out -pI-./

@ "'6av~ 3/1'2/12

NO,t\onu \co.re \'0 (,\ZF

\HoBlY\ole.s

N1P l4·s4

Follow up visit 1 month later

BUN, mg/dLBodywt, kgUUN, g/24 hr

March 597.068.27.1

March 799.069.47.4

7. JZ has been on HD for a month now. At her dialysis visit with you the RD, she tells youthat she has been noticing that her weight has been fluctuating. What can you tell herabout potential weight changes in-between HD sessions? (2 points)

Sodium and f\\l\c\ ore restricted to limit wi· qOliX) \n be:ween dla',/s·I~. cono mere, tnCH1 1. \<~ ~s~G\illLd ~'( da.~,t~ce&S \-.fa GmdfluId c~V\ ,result inedcffiC\. H'S \IC1turcll to See, \-\I'\'. f\uctucrnons beiWeei\ d!'oh/SIS tr~cct1I1e.n:tsbtCGuse t>fwclter C\\"\d v\j(~~e Ye1E:wnon 0 bLtt ane\- ""'Ie ne'(t dicth/SIS \'ession/-\-\'1t n~.'-C\\\1\n5 ''N~\te:r o.nct l1l'L\n~\Ni\\ be f\l\~\\ec\ 001'-, re~L\rti'()9 in decreasedwt. \?>ui Cl~ain \ tdema win CCCIJ: beC(.\\He of 'tVle build u~ of .t~'t.m& ande\ ettv'o\ ~te s , I~ \5 0. C\(ci e a\'\d \~ nOYlY\a\ to na\l~\i\St . f'\UL1uc\ te,

8. You interview JZ at some length. She assures you that she is following her diet. Basedpn her UUN, is she consuming the amount of protein you recommended on her diet'pattern? Show calculations to back up your conclusion. (3 points)

~\jer(.\qe lj)tC\\Le o{proielY}':: (02.5 £3

N-bC\\c\nCt;; (Ol.s~ _ ("L!-t4') -;:; \O-1I.4 = -i.4~/(0, :25

TZ i~ f()O~-\ l\f \i\Leiy tOf\SUmi0<j the '(e.C)ct CHY\c\JDt err -prote.\O oeoruse -the.N-bc\\C\i\ce \S C\t)S'e:: '\0 zero (\na ·fu\lt; between he.r ree-d pl1JteJt1 Y--an~cof 5S-10~i\'~\"\\(\\ ~i\J~ 0. ~-bG\\G\nc.~of ~2,(oto -b.2~1' Plus, N-bC\ICl\1Cemo.y\lot bt tcmplt\-e1i <i\c..~urC\te bNG\US e It- fal ISTh a((ou~ for reml (rf\\JC\{rme\l+.'&\t N~ba\Qnce ~\icmo\) C()\,lla be used to re~t'Ja'udte 0'2'6 estimat(t\ needs.

9. The patient tells you she sometimes uses a salt substitute. Is this appropriate and whyor why not? (1 point)

\t \S \'\01 C\?prcvricne -\1)r '-\he Vt. to (O\ls\.une sa\t subS1inrtes becaUse 1"\~(\\-\~ut>~1itu'\e~ore. a. (ct\C~t'ltx--C\ted ~ou.r(t or ?\)TC\sS\\.lm c.\i\t.nc.\e.\\iCj\\ amo0ms of- pcstu~s(\lm \f; ~~ ~OOC\ -fu" ?\,S, c\\lnn<j C.\<'D stRqe~ ~nd \10 yn-s.

Renal Diet Pattern/ ~ .,-/

Diet prescription- Pi.'S es'nmtXted \letds Inciucln nSO K(~IJ 55-70 <3 prcje-In I '1SO-1200 rnLf\\A{cl) \OOO-3CCO 1Y\'j \\lC\~<aS-O ff\Cj \JhosrC\Y)d 2.000 m<jV\< wct-\) 501. t18\f, CUrrent rendl diet

tet.s s1i med eec\s bm e m n )~ S'i.

Food (# choices) Kcal Pro (g) Na (mg) K (mg) Phos (mg)SO'/. Ii \3\(

Meat42/(0 ~c\1cm<jes 3QO \SO 000 gQO

Milk100 IC()S 110i Nc\1c.m£jC. \2.D 4

Bread 5 e'A.dlQn9t~ 450 \0 400 1lS" \15

Vegetable 25 I \S" ,0 201- \{)V\J k2 mtc\ K 50 2- 30 300 40i -

1-' \OIN K '10 a,r; - .. /0 I~Fruit 1 tv1ed K \40 \ - 300 30

l- rt'~nK 70 0,£ - 270 \S"

FatlO n.(\r1(l n 9c.s 450 0 sso \00 SO

Extra- - - - -o ei-m(..\flgeJ

\.2 L flUid resmcnor VFluids 0 D 0 0 0vISible t\;2..0 flu(cl

TOTAL \l(oS (0 I Ijv f64S m~../ \2SS- !'fiB 2\r1~ m5

keel! 'PYOteiY'l v v

Pt. can rnee+ esti\1)<xted needs by hCY'JiIlCj CD etchanges of lneClT(sOII1B\I)/ t C"x.C.hc4I19e....

of \rinK I 5 t'){c..\1aV1~S Df bread I i \ow-\< \H~~cmble.ei.thange, 2 med-IL vC'g~bleetc..huI1Cje£ I 1 \ow-\( fruit t¥.d,"'tl3el '2 med~K frMt-e'i--WOh9c,s( .1. th5h~\L- fnllt'eiC.\l(\\1~e I \D fht tid,ul'lges Gw)d a fluid re~trfc1icn of t.2, L.

®

CALCULI\1\ONS

c-)(cha~(~ ;

tv3 'J protein )(. D.S :::-31S Cj ()f "~'l'3\.~ ~ ::: 4.5 ::::V 5 f''t(Vlaoqc -t

-, Cj se:Y-\JiO~

\0 ~tthanqtJ XI ~ .~t2 lj {r()f(\ \\B'\I

t>~ ~ - 41-<1 ~ 2\ Cj from \\on-1tBN

19~9 '" '" ¥((A\ :: 2~'1·V-ta\hum ~-te\f\J

n50 \«"'\ - 252 \,(0\;; \4C\£' ~, f\'1)\'n C.Jto ~ fz:1t

5'2" == 15T.5 em\S8 Ib,\":' II. '0 \(9 (CBW)

\6W:: \00 + (5~2) '"HI) 'b\ ""51J ~'30/. \~W = II ?> rc.) .. x \()(} -;. ;,:- \43.CD"/

50~9 1<>.

\1c.a\ \ 35 I<u-II! kg \BW3~ kcal x 50 K<j : /I'-;() I(.(...cll

\~rtJtelhJ I. I ...L 4 'J I \Uj 16\N

I·\ q )£ 5b t!--':) :' Sf) 31.4 'j x: so ~_j .,., 10 ~ cWGj :::-(o?> 9

[~'Uid I r;oo - "1;:0 ml, t VVlne b\}fputi

g:X:Yt <':\9) ml::- 9S() ml,SO i 4-S0 ~lL i: \100 mL

srrn- 1'- '6 ~..9 =- 2..8.Q ~Jf()2.

(,.5151f1Y· «()~enMe,'~)

{rhoS' L \T tn<j/l!-~ \8'N

\1 Wll1 )( so ~Gj""- RS'b m9

\ t\1t\, \)1.1 ddded ~G1\t ~ :1-~ 'j IdfAy

(El ~ m~/~ \6"".it 0 f(\fj t S'b l!-:\ =- 20CJ.) ro3

\<.t: 2(PQ ()_ 'I. Ico'I.:. \~S '].~OOO

tD2 )( \oo·j. ~ \~2'1.-(06

F~os', \'0(01. S ").lOO'/.:- 219-/5So

pro -.