Sage Dietetic Internship - NCP Form



Sage NCP Form Student Name: Kimberly LaBrecque Case No. 19

|Patient: Ms. C |Referred for: Nutrition Counseling and Education on Dialysis Diet |

|NUTRITION ASSESSMENT |

|Food and Nutrition Related History: Patient is a married, 49 year old female status post kidney transplant x 2 due to history of membranoproliferative |

|glomerulonephritis diagnosed 15 years ago. Patient has previously been treated with hemodialysis and peritoneal dialysis and is currently admitted for acute kidney|

|rejection and chronic allograft nephropathy as well as insertion of peritoneal dialysis catheter to initiate dialysis. Patient would like to continue CCPD so she |

|can work during the day. Patient reports dyspnea, nausea and reduced appetite due to bad taste in food. Patient also has a history of hypertension, anemia related|

|to chronic kidney disease and dyslipidemia. |

| |

|Anthropometric Measurements |

|Age: 49 |Gender |Ht: 157.4 cm |Wt: 77.1 kg |BMI: 31.1 |

| |Female | |Wt Hx: 74 kg |Usual BMI: 29.9 |

|Biomedical Data, Medical Tests & Procedures |

|Labs/Date |

|Pertinent Medications/Supplements/Herbs: |

|Procardia, carvedilol, Catapres, CellCept, fish oil, Lasix, prednisone, Gengraf, Prinivil, sodium bicarbonate, calcitriol, renal caps and Renvela |

|Skin status: X Intact □ Pressure Ulcer/Non-healing wound; Comments: |

|Patient/Client/Family Medical/Health/CAM History: |

|Patient: membranoproliferative glomerulonephritis; allograft transplant X2; hypertension; dyslipidemia; anemia of chronic kidney disease |

|Family History: Mother – cervical cancer; Father – lung cancer |

|Estimated Nutritional Needs Based on Comparative Standards: |

|Calories |Protein |Fluid |

|Pre-dialysis: 1500 to 1600 kcal/day for weight |Pre-dialysis: 41 to 45 g/day minimum based on the |Pre-dialysis: 2000 mL to 2400 mL/day |

|maintenance (based on Mifflin St. Jeor formula and |patient’s adjusted body weight and current body |(30 to 35 mL/kg adjusted body weight) |

|stress factor of 1.1 to 1.2) |weight (allowing for net fluid gain of 2 kg) | |

| | |Once dialysis commences: minimum of 2000 mL/day (30 |

|Once dialysis commences: 1800 to 1900 kcal/day based |Once dialysis commences: 82 g to 89 g/day per KDOQI |mL/kg adjusted body weight) |

|on KDOQI guidelines of 35 kcal/kg, allowing for 60 to |guidelines of 1.2 to 1. 3g/day for patients on | |

|70 percent glucose absorption from dialysate |peritoneal dialysis | |

|Current Diet Order |Feeding Ability |Oral Problems |Intake |

| |x Independent |□ Chewing Problem |□ Good (> 75%) |

|1500 kcal, 75 g protein, |□ Limited Assistance |□ Swallowing Problem |X Fair (approx. 50%) |

|3000 mg Na, 3500 mg K, |□ Extensive/Total Assistance |□ Mouth Pain |□ Poor ( ................
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