FScN 4665 - Medical Nutrition Therapy II – Spring 2014



Your Name and/or Name of Partner (if working with one):_______________________Jessica Zuck___________________________________________Danielle Nabak____________________University of Minnesota - Department of Food Science & NutritionFScN 4665 - Medical Nutrition Therapy II – Spring 2014Case 2100 PointsAdapted from Morrison, G., Stover, J. Case 1 Chronic Renal Failure: Advancing to Dialysis, in Integrative Systems and Disease, Chapter 11, Part III. pp. 350-359. Due Date: April 16, 2014Please be sure to do the following:Show all calculations, and explain your rationale. Calculations do not have to be typed.Answer all questions directly on this form. Type all answers (except calculations). Submit in hard copy in class on the due date. You will be deducted one point per day after the due date until the hard copy is turned in.You may work ALONE or with ONE other person. Do not share your work with other individuals beyond your group. If you work with a partner, you should hand in only ONE case with your name and your partner’s name clearly listed at the top of the first page. Some resources needed for solving the Case:Krause’s Food and the Nutrition Care Process, 13th edition. Chapter 36: Medical Nutrition Therapy for Renal Disorders.Lecture notes and supplemental readings posted under the class topic “Renal Disorders” in the Moodle site, particular the Chronic Kidney Disease notes and materials at the end of the note set.I have created two Excel files that will help you calculate AB’s current intake, and your recommended diet plan for AB. These are posted with the case on Moodle, and are labeled as follows:“Case 2 Worksheet for Analysis of AB’s Current Intake” - contains formulas that will help you evaluate AB’s current diet using National Renal Diet Food Lists“Case 2 Worksheet for Renal Diet Calculations” – contains formulas that will help you devise your renal diet plan for AB. The following note sets are from MNT-1. These are posted in the Moodle under “Reference Materials and Resources for Cases” “Selected FSCN 4665 MNT I Course Materials for your Reference”:Nutrition Assessment I-History and Physical ExaminationNutrition Assessment II- AnthropometryNutrition Assessment III-Biochemical/LaboratoryModule I: Nutrition Care Process, Nutrition Diagnosis and Medical Record DocumentationModule II: Energy, Protein, and Fluid Requirements in the Clinical SettingAcademy of Nutrition and Dietetics: Evidence Analysis Library Nutrition Guidelines on Chronic Kidney Disease. Link to EAL website is posted in MoodleWhite JV, Guenter P, Jensen GL, Malone A, Schofield M. Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). JPEN 2012;36(3):275-283.KDOQI Guidelines: Nutrition in Chronic Renal Failure (PDF Download from National Kidney Foundation site).Brown, Compher, et al. ASPEN Clinical Guidelines: Nutrition Support in Adult Acute and Chronic Renal Failure. JPEN July 2010; 34(4):366-377. IDNT ManualPart I.AB, a 22-year-old Caucasian college student, presented to the emergency room with headaches and shortness of breath (SOB). He was admitted to the hospital for evaluation when he was found to have a blood pressure of 200/120 mm Hg and mild congestive heart failure (CHF). AB reports that over the past year, his weight has increased approximately 10 lb., although his diet has remained unchanged. He attributed this weight gain to decreased exercise and a busy class schedule.Past Medical HistoryAB has had no recent viral illness, sore throat, or upper respiratory infection. He has never had rheumatologic symptoms and has no family history of renal disease. He had a history of multiple streptococcal infections of the throat as a child, some of which were treated with antibiotics and some that went undiagnosed. He is currently not taking any medications, vitamins, minerals, or herbal supplements, and has no known drug or food allergies.Social HistoryAB’s roommate at the dorms is a fellow student in good health. AB denies alcohol, tobacco, or oral drug use. AB’s 24-Hour Diet HistoryBreakfastCoffee, 8 oz, brewed strongWhole milk,? cup, heated, and mixed with coffeeFried egg, 12 slices whole wheat toast with 2 Tbsp ButterOrange juice, 8 ozLunchCheese burger (3 oz burger, white bun, 1 oz cheddar cheese)Potato chips (2 oz)1 medium bananaCoke, 12 ozSnackPretzels, 1.5 ozCoke, 12 oz CokeDinner1 cup cream of mushroom soup made with milkBaked potato,1 medium with 2 Tbsp Butter and 1/8 tsp season saltSteamed broccoli, 1 cupSmall salad made with iceberg lettuce, 1 cup total with 2 Tbsp Wishbone Italian dressingSnickers bar, 2 ozCoke, 16 ozSnackDry roasted salted peanuts, 1 ozCoke, 12 ozReview of SystemsGeneral: Fatigue, weakness, SOBGI: AnorexiaPhysical ExaminationVital signs:Temperature: 97° FHeart rate:96 beats per minute (BPM)Respiration: 24 BPMBP: 200/120 mm HgGeneral: well-developed manLungs: decreased breath sounds with faint crackles at the right baseCardiac:regular rate and rhythm, systolic murmur at the apex, S3 gallopAbdomen:Soft, nontender, no hepatomegalyExtremities: 3+ peripheral edema on both legs, ring tight on fingerSkin:Warm to touchNeurologic:Intact, mild asterixisAB is 5'9" tall. His current weight is 77.3 kg.; Usual body weight (UBW): 70.5 kg. (6 mo. ago). Standard body weight by NHANES tables: 78 kg The following lab work was done:Urinalysis: Protein 1+, 3+ hemeLab TestResultNormal RangeNa+135 mEq/L136 – 145 mEq/LCl-111 mEq/L95 – 107 mEq/LK+5.8 mEq/L3.5 – 5.0 mEq/LBUN108 mg/dL8 - 25 mg/dLCr14.0 mg/dL0.8 - 1.2 mg/dL (men)Phosphorus10.2 mg/dL2.6 - 4.5 mg/dLCalcium7.5 mg/dL8.5 - 10.8 mg/dLAlbumin3.2 g/dL3.5 - 5.0 g/dLMCV70 fL80-100 fLHct24.3%42 - 52% (men)Hgb8.3 g/dL14 - 18 g/dL (men)CO215 mEq/L24-32 mEq/LTransferrin saturation18%>20% (CRF)Ferritin142 ng/mL>100 ng/mL (CRF)WBC8.7 x 109/L4.5-11.0 x 109/LUrinalysisUrinalysis reveals blood and protein, indicating renal glomerular damage. RBC casts are highly suggestive of glomerulonephritis, and broad waxy casts suggest dilated renal tubules associated with chronic glomerulonephritis (CGN).24-Hour Urine CollectionThis procedure reveals the quantity of protein and creatinine excreted over 24 hours. If the amount of urinary creatinine can be measured in a 24-hour urine specimen, a creatinine clearance can be calculated.Protein Excretion2.2 g per 24 hours, normal value <200 mg per 24 hours Creatinine ClearanceEstimation of creatinine clearance can be calculated using the MDRD equation. AB’s estimated creatinine clearance = 9.05 mL/minNormal creatinine clearance for a male = 97–137 mL/minRenal UltrasoundRenal ultrasound revealed small kidneys bilaterally, which indicate irreversible renal disease (9 and 10 cm, right and left, respectively). Only a renal biopsy could actually confirm the dx of CGN, but it is not performed once small kidneys are identified since no treatment can reverse the kidney damage. AB’s significantly increased serum phosphate and decreased serum calcium suggest that the GFR is less than 30 mL per minute, indicating significant renal dysfunction. His estimated creatinine clearance in fact suggests that the GFR is below 10 ml/min.Tests to eliminate other possible causes of CGN include the following. Complement LevelsCH50, C3, C4 are all WNL (makes the dx of membranoproliferative disease, subacute bacterial endocarditis, an acute poststreptococcal glomerulonephritis highly unlikely). 24-Hour Protein CollectionEliminates the dx of nephrotic syndrome. AB’s hx and physical examination eliminate other causes of CGN, such as Alport’s syndrome. As a result of all the diagnostic tests, and in light of his physical examination, biochemical, and other medical data, AB is diagnosed with chronic glomerulonephritis (CGN) and stage 5 CKD. 24-hour urine collection revealed that AB’s urine output is approximately 750 ml/day. His nephrologists informs AB that he needs to be treated with dialysis. He decides, with his physician, that he will go on CAPD when he is discharged to home. The regimen will be: four 2-liter 1.5% PD exchanges daily. UNDERSTANDING THE PATHOPHYSIOLOGY:Based on AB’s history, explain the most likely cause of his CGN. (2 points)The most likely cause of AB’s CGN is his history of multiple streptococcal infections of the throat as a child, some of which were treated with antibiotics and some that went undiagnosed. The undiagnosed and therefore untreated cases of streptococcal infections are likely what caused the CGN.Explain the pathophysiology that is most likely driving AB’s hypertension and edema. (2 points)Glomerular injury causes increased glomular permeability. This increased permeability allows proteins that normally wouldn’t be filtered to be filtered leading to proteinuria. Hypoalbuminemia can result from proteinuria which leads to edema as well as decreased plasma volume. The decrease in plasma volume activates the rennin-angiotensin-aldosterone system leading to Na+ and water retention, which consequently worsens edema, as well as contributes to hypertension. Other causes of hypertension include dysfunction of the autonomic nervous system (baroreceptors) and vasodilator deficiency.NUTRITION ASSESSMENTAnthropometric and PE DataWhich body weight will you use as the most “accurate” weight to reflect his “actual” or “dry” (i.e. ‘edema-free’) body weight for your assessment? EXPLAIN your thinking, using support from AB’s physical examination data and any other relevant information from AB’s medical data and history. (2 points)We will use AB’s usual body weight of 70.5 kg as the most accurate weight to reflect his edema-free body weight for our assessment. While AB’s current weight is 77.3 kg., this is likely elevated due to his edema as evidenced by 3+ peripheral edema on both legs and ring tight on finger. In addition, AB reports that over the past year, his weight has increased approximately 10 lb., although his diet has remained unchanged. He attributed this weight gain to decreased exercise and a busy class schedule. It is likely that his weight gain was actually due to fluid retention and edema, which are results of his declining renal function. Evaluate the weight you chose in #3 by calculating AB’s BMI at that weight. Into which category does AB fall, based upon the National Institutes of Health, National Heart, Lung, and Blood Institute’s Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, which was provided in the “Nutrition Assessment II: Anthropometry” notes in FSCN 4665? (2 points)AB’s BMI = 70.5kg/(1.75m)2 = 23.0 kg/m2AB falls into the category of normal weight with a BMI of 23.0kg/m2.Evaluate AB’s edema-free body weight (identified in #3) in terms of % of the standard weight determined by NHANES tables (this was provided in the case scenario). (2 points)Standard body weight by NHANES tables: 78 kg 70.5kg/78kg = 90.38% of standard body weight. AB’s edema-free body weight is 90.38% of the standard body weight according to the NHANES tables.Do you intend to adjust his edema-free body weight, or use it as it is, for your assessment of nutrient needs? Explain the rationale for your choice. If you do intend to adjust his weight, go ahead and calculate it here. (2 points)The calculation (in Question #5) of AB’s body weight being less than 95% of the standard body weight for a man of his height indicates that we should adjust his edema-free body weight. Despite this fact, we have chosen not to adjust AB’s edema-free body weight. We made this decision based upon the fact that AB’s BMI places him safely in the middle of the “normal weight” category, thus indicating that he is not underweight. In addition, the standard body weight was based on NHANES data that is skewed upward due to the large proportion of the population in the US that is overweight/obese. Thus, we do not intend to adjust AB’s edema-free body weight for future assessment of his nutrient needs.Biochemical DataExplain what is happening to AB’s calcium-phosphorus balance. Explain the pathophysiology driving any abnormalities that you observe in his serum concentrations of calcium and phosphorus. Discuss what you know about the role of PTH and vitamin D. How might renal osteodystrophy result if these abnormalities remain untreated? (6 points)AB exhibits low serum calcium (7.5mg/dL, N:8.5-10.8mg/dL) and high serum phosphorus (10.2mg/dL, N:2.6-4.5mg/dL). Low serum calcium triggers the further release of PTH, which decreases serum phosphorus by decreasing its tubular reabsorption and increasing its secretion. This triggers osteoclastic resorption of calcium from bones. The normal mechanism by which PTH stimulates increased vitamin D activation is not working on the failing kidneys, thus GI absorption of calcium is not increase by PTH in CKD. This decrease in active vitamin D decreases the Ca absorption. Patients also experience metastatic calcification (a deposition of Ca-P salts), which causes serum calcium to fall. The low calcium and high phosphorus levels that AB exhibits are signs that GFR has fallen below ~30mL/min.Renal osteodystrophy occurs when PTH stimulates the release of calcium from bone by osteoclast activity. Thus begins metastatic calcification of joints and soft tissues, osteomalacia and osteitis fibrosa cystica. All of these manifestations occur due to hyperparathyroidism. Discuss the interventions required to normalize serum calcium and phosphorus values in CKD patients. Indicate the order in which the interventions should be initiated, and explain why. (4 points)In order to normalize serum calcium and phosphorus levels, individuals with CKD must restrict phosphorus. There is evidence that early phosphorus restriction may retard the progression of CRF. Phosphorus restriction should begin when serum phosphorus is above 4.5mg/dL, or when PTH is above the target range for the specific stage of CKD. The recommendations for phosphorus come from the K/DOQI guidelines, and are <12 mg/g of protein or 800-1000mg/day. Foods that are high in phosphorus include dairy, meats, legumes, nuts, colas and chocolate. One way to help restrict phosphorus is to take phosphorus binders with meals. These will help keep serum phosphorus within a normal range; they work by forming insoluble complexes between dietary phosphorus and the cation of the binder. There are two types of binders—calcium-based and non-calcium containing. Renvela is a non-calcium containing phosphorus binder that has a bicarbonate buffer, and does not contain calcium, magnesium or aluminum. This means that there is less risk of acidosis and metal toxicity. After blood phosphorus levels have decreased, then calcium supplementation can be advised as needed, to maintain normal total corrected serum Ca. 1000-1500mg/day can be supplemented but total intake, including any calcium that might come from a calcium-containing phosphorus binders, should be < 2g elemental Ca per day. If constipation, nausea and/or flatulence persist as a result of Ca supplementation, activity, fiber supplements or stool softeners are recommended. Early phosphorus restriction and Ca supplementation may prevent secondary hyperthyroidism.Indicate which lab values suggest that AB is anemic. What is the most likely reason for AB’s anemia? (4 points)AB’s labs show low Hgb (8.3g/dL, N:14-18g/dL) and low Hct (24.3%, N:42-52%). Both of these are indicative of anemia. The most likely cause of AB’s anemia is the increased destruction of RBCs by uremic waste. AB’s urinalysis revealed blood and protein, indicating renal glomerular damage. RBC casts are highly suggestive of glomerulonephritis. More??Dietary Intake DataUsing AB’s dietary intake data:Keeping in mind dietary recommendations for individuals who have CKD who will be on peritoneal dialysis, evaluate AB’s diet PTA using the National Renal Diet Food Lists, where possible, in light of the 1) phosphorus and 2) protein content. Use the “Case 2 Worksheet for Analysis of Abs Current Intake” Excel file posted along with the case to calculate the values, being careful not to disturb any of the cells containing equations or formulas! The first tab “Convert Diet into Food Groups” is where you will find his dietary information entered and you will need to translate each food into servings from the various food groups given to you at the end of the CKD notes (Table 34.2 “Average Calculation Figures for Planning the Diet for ESRD”). The second tab “Nutrient Calculation Sheet” in the above named Excel file will allow you to calculate the nutrients from the various food list categories you determined from the worksheet at the first tab. You just have to enter in the number of servings of each of the food groups and it will tally the phosphorus and protein (and you can also see the sodium, potassium, and kcal content if you’re interested but you don’t have to do anything with that information for this exercise). For cream soup, Snickers, and peanuts (which are not clearly found on the Food Lists), I have entered in the phosphorus and protein values for you. The Excel file is set up to give you a grand total of phosphorus and protein (including these three foods) highlighted in yellow. Report the value you obtain for the grand total of protein and phosphorus in AB’s diet below. If you prefer not to use my Excel worksheet, you can do your calculations by hand. AB’s Estimated Current Phosphorus and Protein Intake: (4 points)Phosphorus1428 mgProtein74.5 gHow many kcals will AB likely absorb per day from the CAPD dialysate solution? Show your calculations. (3 points)Regimen: Four 2-liter 1.5% PD exchanges daily CAPD = ~60% absorption4 x 2 L = 8 L/day8L/day x 15 g dextrose/L = 120 g dextrose/day120 g dextrose/day x 3.4 kcal/g dextrose = 408 kcal/day408 kcal/day x .6 = 244.8 kcal/dayAB will likely absorb about 244.8 kcal/day from the CAPD diaslysate solution.Once you have estimated AB’s current intake, you should compare it to the recommended dietary intake strategies you would make for AB, now that he will be on peritoneal dialysis (CAPD).First, specify the recommendations you would give to AB appropriate for PD with regard to total daily intake of kcals, protein, phosphorus, supplemental calcium and vitamin D, sodium, fluid, and potassium, showing all relevant calculations. Refer to your CKD class notes to formulate your recommendations, and be specific in terms of total quantities. Be sure to think carefully about which weight you will use for your assessment. (8 points)Energy:(and don’t forget to subtract out the kcals absorbed from the PD dialysate)Protein:Phosphorus:Supplemental calcium and vitamin D:Sodium:Potassium:Fluid:Now assess AB’s current dietary intake further, identifying ‘problem areas’, i.e. high sodium, high potassium, and high phosphorus foods/beverages that AB is consuming. Then evaluate his current dietary intake in specific terms for phosphorus and protein intake (from your calculations in question # 10), by making a comparison to what AB should be consuming in order to be in compliance with the recommendations for nutrition management with PD. Current intake vs. recommended intake: High-sodium foods/beverages that AB is currently consuming (2 points)CheeseburgerPotato ChipsCream of Mushroom SoupSalted PeanutsMilkHigh-potassium foods/beverages that AB is currently consuming (2 points)BananaMilkBeefPotato ChipsOrange JuicePeanutsHigh-phosphorus foods/beverages that AB is currently consuming (2 points)CokeCream SoupPeanutsWhole Grain BreadCurrent phosphorus intake compared to recommended intake (give specific numbers for comparison, and evaluate if too high, too low or acceptable) (2 points)Coke – 52oz. ~ 200mg phosphorusCream Soup – 1cup ~ 275mg phosphorusPeanuts – 1oz. ~ 100mg phosphorus (would be a concern in greater amounts)2 slices WG Bread ~ 160mgMilk – ? cup ~ 111mgPotato Chips – 2oz. ~ 100mgCheddar Cheese – 1oz ~ 143mgGround Beef – 3oz. ~ 165mgSnickers Bar – 2oz. ~ 110mgOther foods in AB’s diet have insignificant amounts of phosphorus (>80mg/serving)Currently, AB ingests around 1,370mg of phosphorus without the insignificant amounts added.This amount is too high for someone with CGN and stage 5 CKD. Recommendations for treatment of CKD and predialysis is limiting phosphorus to 800-1000mg/day, or <12mg/g protein consumed. Current protein intake compared to recommended intake (give specific numbers for comparison, and evaluate if too high, too low or acceptable) (2 points)NUTRITION DIAGNOSISRefer to the Jensen article (Jensen GL, Hsiao PY, Wheeler D. Adult Nutrition Assessment Tutorial. J Parenter Enteral Nutr 2012;36(3): 267-274.) and the ASPEN/Academy Consensus Statement (White JV, Guenter P, Jensen GL, Malone A, Schofield M. Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). J Parenter Enteral Nutr 2012;36(3):275-283.) to determine if AB meets the definition of a specific category of malnutrition. Explain your rationale. (2 points)Based on what you discovered in earlier questions, identify TWO of AB’s most prominent nutrition-related problems using the standard Nutrition Diagnostic Terminology and INCLUDE the CODE # from the IDNT manual for each nutrition diagnosis you write. Nutrition Diagnosis #1: (3 points)Nutrition Diagnosis #2: (3 points)For each nutrition diagnosis, write a complete nutrition diagnostic statement in PES format (problem, etiology, signs and symptoms), labeling each section (P, E, and S) appropriately. PES #1: (3 points)PES #2: (3 points)NUTRITION INTERVENTIONPrepare yourself for providing nutrition education and counseling to AB. Thinking back to your evaluation of AB’s dietary intake data from question #12b, identify at least 5 foods/beverages in his current diet that he could change in order to better comply with the renal dietary restrictions you have recommended. Be sure to explain why each particular food or beverage is a problem. Suggest possible substitutions for each of these problem areas that AB could make in order to accommodate the dietary restrictions he needs to follow. (5 points)Explain to AB (in easy-to-understand, lay language) why you want him to follow the recommendations you made for protein, phosphorus, calcium, vitamin D, and sodium. (5 points)Protein:Phosphorus:CalciumVitamin DSodium:Follow-UpAB did fairly well on CAPD for 3 months until he began to have difficulty with the draining of PD fluid through his dialysis catheter. He had repeated doses of a thrombolytic agent infused into the catheter in an attempt to dissolve the proteinaceous material, with only minimal success. He eventually had a new catheter inserted that only worked temporarily before the same problem developed. He was subsequently readmitted to the hospital for an HD catheter and started regular outpatient hemodialysis treatments. At that time his urine output had declined to less than 200 mL per 24 hours. AB has requested that you (the RD) now provide him with a more detailed diet plan that he can follow.Calculate a meal pattern for AB in compliance with the dietary recommendations for individuals on hemodialysis. Start by calculating his nutrient needs for HD (including protein (total and HBV), kcal, fluid, sodium, phosphorus, and potassium. NOTE that there may be important differences between what you recommended previously for AB when he was on CAPD compared to what you recommend for him now that he is on hemodialysis. Please show your work in the space below, and write in your numbers on the following page. (6 points)Protein (total and HBV)KcalFluidSodiumPhosphorusPotassiumDiet Rx:_________ g protein, with at least______ g HBV protein________ kcal________ ml fluid________ mg Na+________ mg phosphorus________ mg potassiumAverage Calculation Figures for Planning ESRD Diet (REVISED)Food ChoicesProtein (g)Na+ (mg)K+ (mg)Phos (mg)KcalMilk and Dairy4.08018511060**Almond Milk (1/2 cup)0.576601046 Soy Milk (? cup)3.5451656040Nondairy Milk Substitutes0.5408030140Meats7.0251006565*Tofu (? cup)10.01015012095 *Legumes (? cup)8.0-340130110*Peanut butter (2 Tbsp)8.015023010095Starches2.080353590Vegetables Low K+ 1.015702025 Medium K+ 1.0151502025 High K+ 1.0152702025Fruits Low K+ 0.5Trace701570 Medium K+ 0.5Trace1501570 High K+ 0.5Trace2701570FatsTrace5510545High-Calorie ChoicesTrace15205100Salt Choices----250------------** NOTE: In your handout from the Manual of Clinical Dietetics, the average kcals listed for the milk and dairy group is 120 kcals for a ? cup serving. This is an averagebased upon a wide range of products that fit in this group. If you simply plan for the consumption of 2% milk, use 60 kcals. Refer to complete food lists in CKD notes packet for serving sizes of foods withineach group. *These are only a few choices for vegetarians. Refer to information in the CKD notes packet on planning vegetarian renal diets.Baseline Calculations: Determine the number of servings in each food group based on the diet prescription. Calculate the nutrient values and add to get the subtotals. NOTE: IT IS ACCEPTABLE TO BE WITHIN ± 100 mg Phosphorus, ±100 mg Potassium, ±50 Kcal, ±1 g Protein, and ± 500 mg Sodium of your goal targets in your calculated pattern. (6 points)*Relevant for vegetarian meal plan or in specific circumstances based on diet recall onlyFood Choices# ServingsProtein (g)Na+ (mg)K+ (mg)Phos (mg)KcalMilk and Dairy*Soy MilkAlmond MilkNondairy Milk SubstitutesMeats*Tofu *Legumes*Peanut Butter*Other non-meat ________StarchesVegetables Low K+ Medium K+ High K+ Fruits Low K+ Medium K+ High K+ SUBTOTALSNext, determine number of fat and high-calorie servings based on caloric needs and calculate nutrient values. Keep in mind that you may not need to add any high-calorie choices. Total values and adjust number of servings as needed to meet caloric needs and patient’s food preferences. (2 points)Food Choices# ServingsProtein (g)Na+ (mg)K+ (mg)Phos (mg)KcalSUBTOTALSFatsHigh-Calorie ChoicesTOTALSNa+ allowed in diet prescription: ____________ mg SUBTRACT Na+ calculated in pattern - _____________mg = ____________mg Na+ (1 point)This is the remaining Na+ allowed to be distributed in the form of added salt or condiments (salt choices). One salt choice contains ~250 mg sodium. Keep in mind that you may not deem it necessary to provide any salt choices to Mr. D, depending upon your calculations in part b, and your assessment of Mr. D’s need for a sodium restriction. Help AB see how he might plan meals using the meal pattern you calculated. Plan out a day’s meals with AB. (7 points) ONE DAY MENU BASED ON CALCULATED DIET PATTERNBREAKFAST#ServingsFood GroupMenu ItemMilkSoy MilkAlmond MilkNondairy Milk SubstitutesMeatsTofuLegumesPeanut ButterOther non-meat:StarchesFruits – low K+Fruits – med K+Fruits – high K+Vegetables – low K+Vegetables – med K+Vegetables – high K+FatsHigh-Cal ChoicesLUNCH#ServingsFood GroupMenu ItemMilkSoy MilkAlmond MilkNondairy Milk SubstitutesMeatsTofuLegumesPeanut ButterOther non-meat:StarchesFruits – low K+Fruits – med K+Fruits – high K+Vegetables – low K+Vegetables – med K+Vegetables – high K+FatsHigh-Cal ChoicesDINNER#ServingsFood GroupMenu ItemMilkSoy MilkAlmond MilkNondairy Milk SubstitutesMeatsTofuLegumesPeanut ButterOther non-meat:StarchesFruits – low K+Fruits – med K+Fruits – high K+Vegetables – low K+Vegetables – med K+Vegetables – high K+FatsHigh-Cal ChoicesSNACKS (SPREAD THROUGHOUT DAY AS NEEDED)#ServingsFood GroupMenu ItemMilkSoy MilkAlmond MilkNondairy Milk SubstitutesMeatsTofuLegumesPeanut ButterOther non-meat:StarchesFruits – low K+Fruits – med K+Fruits – high K+Vegetables – low K+Vegetables – med K+Vegetables – high K+FatsHigh-Cal ChoicesNow that AB is on hemodialysis, he needs to be much more careful with his fluid intake. Describe 3 tips/strategies that you can you recommend to AB to help him stay within his fluid restriction. (3 points) ................
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