NS335 Nutrition for Special populations

Unit 5 Assignment: A Patient with Diabetes Receiving Dialysis

Unit outcomes addressed in this Assignment:

• List the nutrient requirements for adults with renal disease based on type of renal impairment.
• List the goals of medical nutrition therapy in the management of end stage renal disease.

Course outcomes addressed in this Assignment:

NS335-2: Explain how nutrition assessment results can impact the nutrition intervention plan in a person with a chronic disease.

GEL-1.02: Demonstrate college-level communication through the composition of original materials in Standard English.

Assignment Introduction:

Imagine that you are a nutrition education assistant who is working at the county health department’s nutrition outreach program. You have received a patient referral from the local dialysis center. While all dialysis centers have nutrition professionals, and nutrition education is reimbursed through insurance, Medicare, or Medicaid, this is a serious case of noncompliance, and the dialysis center is trying to gather more support sources for the patient. The supervising nutrition director has assigned you to review the referral information to prepare an appropriate intervention.

Referral Information: Mr. D is a 51-year-old male with poorly managed type 2 diabetes for over 15 years and has been on dialysis three times a week for 1 year. Medical records reveal that his diabetes was most likely obesity related and was never well controlled. Mr. D required insulin shots soon after his initial type 2 diabetes diagnosis. One year ago his friend found him unconscious in his apartment and took him to the hospital. Upon admission, his blood glucose was over 650 mg/dl. He was already showing signs of kidney disease prior to hospital admission. His friend reported he rarely saw Mr. D check his blood sugar or administer insulin shots. His friend also informed the hospital’s nurse that Mr. D once told him it was possible for him to lose weight quickly by letting his blood sugars get really high by skipping insulin doses.

From Chart: Patient Summary:

Mr. D was 36 years old when he was first diagnosed with type 2 diabetes.

Weight at age 36: 270 pounds (15 yrs ago)

Height: 5’9″

Diet order: 1,800 calorie diabetic diet

Clinical progression of disease: Pancreatic function declined and insulin resistance increased due to Mr. D’s dietary and medical noncompliance.

Medical intervention: Short- and long-acting insulin shots were added to his therapy about 10 years ago.

Hospital and physician visits: Multiple recorded diabetic ketoacidosis (DKA) episodes are documented, including the DKA episode that ultimately caused his kidneys to fully fail when his friend found Mr. D unconscious in his apartment.

Hemodialysis Center reports:

12 months of Hemodialysis (HD) on Mondays, Wednesdays & Fridays.

Weight 1 year ago (age 50): 188 pounds (dry weight measured after dialysis session)

Current age: 51

Current weight: 165 pounds. The patient has lost ~13% of his “dry weight” (commonly used with dialysis patients to obtain a more accurate weight due to fluid fluctuations).

Height: 5’9″

Labs: His sodium, potassium, BUN, Cr, glucose are all out of range and very inconsistent (sometimes very high and sometimes very low, but rarely normal or consistent).

Urine output: Negligible (little to NO urine output due to kidney failure which is the reason for dialysis)

Dialysis compliance: Only attends dialysis sessions about 75% of the time.

Dietary information: Increased calorie renal diet, carbohydrate restrictions, high protein and a 1,250 ml fluid restriction (unless otherwise ordered).

Dialysis nursing notes: Heavy alcohol (ETOH) consumption, often complains of (c/o) nausea/vomiting (N/V) after dialysis, and he usually appears very somber.

Instructions:

Address the following questions in a paragraph format:

• Identify the two main causes/risk factors associated with ESRD (dialysis). How does poor management of type 2 diabetes alter kidney function? Include supporting references along with patient information to support your answers.
• Accurately explains how poor management of type 2 diabetes contributes to the risk of ESRD/dialysis by using credible sources.
• Why did Mr. D’s kidneys fail (requiring dialysis)? Why was Mr. D’s risk for developing end-stage renal disease (ESRD) higher compared to other type 2 diabetic patients?
• Explain how excessive weight loss occurred prior to dialysis. Include an explanation of a metabolic process linked to diabetes-associated weight loss (pre-dialysis). Then, describe why a 13% weight loss occurred since hemodialysis started. Include supporting evidence.
• Choose 3 applicable nutritional diagnosis phrases/nutrition problems from the phrases listed on the Nutrition Diagnostic Terminology document in Course Resources. Which one is the most important and applicable to his current situation and why?
• What are Mr. D’s current estimated calorie and protein needs? Why do dialysis patients require so much protein?
• Identify a community outreach/support program & describe how it can assist a patient similar to Mr. D. Identify a counseling technique and explain how it may increase dietary compliance.
• How can Mr. D’s compliance be monitored and assessed? Which assessment methods and tools should be utilized? Types/classifications of methods: Assessment, Biochemical, Clinical, Dietary (weight monitoring, clinical/social referrals, labs, etc.).

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