ADIME

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NUTRITION ASSESSMENT
Patient name: Joaquin, Enez
Age: 24 Gender: female
Diagnosis: Stage 5 CKD
Pertinent medical history: Diagnosed with T2DM at 13 years of age, poorly compliant with diabetes
prescription. Diagnosed with stage 3 chronic kidney disease 2 years ago, has progressed to stage 5.
Diet order: 35 kcal/kg, 1.2 g of pro/kg, 1 g Phosphorous, 2 g of Na, 1000 mL + urine output
Medications: Glucophage (850 mg bid), Capoten/captopril (25 mg bid), Erythropoietin (30 units/kg),
sodium bicarbonate (2g), renal caps (1 daily), Renvela (3/times daily w/ meals), Hectorol (2.5 pg 4/times
a day 3/times a week)
Labs:

Low Sodium*(130mEq/L)
• Ref Range: 136-145mEq/ L
High Potassium* (5.8mEq/L)
• Ref Range: 3.5-5.1mEq/L
Low Chloride
High CO2
Low Bicarbonate
High BUN
High Creatinine serum
Low BUN/Crea ratio
Low GFR
High Glucose* (282mg/dL)
• Ref Range: 70-99mg/dL
High Phosphate
Low Calcium
High Osmolality
Low Protein
Low Albumin* (3.5-5.5g/dL)
• Ref Range: 3.3g/dL
High Cholesterol
High VLDL
High TG
High HbA1C
Low RBC
Low Hgb
Low Hct
Urine --
High pH
High Protein
High Glucose
High Ketone



Weight: 160.6lbs (73kg)
Height: 5’0” (152.4 cm)
BMI: 31.4k/m2 (obese)
IBW: 100# / 45.4 kg
%IBW: 160.6%

Comments about weight history: 4kg of fluid weight gain in last 2 weeks, using dry weight for weight
based calculations.

Nutrition-Focused Physical Assessment significant for:
3+ pitting edema in the knees
Dry and yellow-ish/brown skin
Rounded, obese abdomen

Summary of dietary intake and food preferences:
Consumes a diet high in refined carbohydrates, fat, processed foods, and sugar sweetened beverages.

Nutrition Impact Symptoms: Patient complains of nausea, vomiting, and anorexia. Due to buildup of
waste products in the blood related to decreased kidney function and stage 5 CKD. NKFA.

Nutrition Needs (provide range and factors)
Calories: 35kcals/kg = 2,555 kcal
Protein: 1.2g/kg = 87.6 g
Fluids: 750-1000mL fluid + urine output

Subjective Global Assessment (include 2 criteria to support your assessment if B or C)
B - Mildly/moderately malnourished
Anorexia affecting oral intake, N/V, edema

NUTRITION DIAGNOSIS: PES Statement (include diagnosis code)
Altered nutrition related lab values (NC-2.2) RT patient being diagnosed with stage 5 CKD and diabetes
AEB high glucose, high potassium, low sodium, low albumin.

NUTRITION INTERVENTIONS
Nutrition Education
Provide information on high phosphorus foods to avoid (nuts, legumes, processed foods, meats, dairy
products, whole grains, and soda)
Educate patient on HBV protein (meat, fish, poultry, eggs)
Educate patient on diabetes management to control glucose levels
Educate patient on controlling potassium intake and high potassium foods
Educate patient on controlling sodium intake
Educate patient on ways to control fluid intake
Custom list of suggestions provided to implement nutrition goals and recommendations.
Substitute bologna for natural meats lower in sodium (IE turkey or chicken)
Substitute potatoes for low potassium alternatives (peaches, apples, carrots, cauliflower)
To control fluid intake: suck on ice chips, chew gum, eat frozen fruits, consume tart foods
Substitute coke with carbonated flavored water (IE La Croix)

Coordination of Care
Collaboration and referral
Renal Dietitian
Diabetes Educator
Goals
Bring electrolytes within a normal range
Sodium (135-145 mEq/L)
Potassium (3.5-5.0 mEq/L)
Chloride (96-106 mEq/L)
Phosphorous (2.5-4.5 mEq/L)
Increase consumption of protein to 1.2g/kg/d to increase serum albumin levels to normal ranges (3.4 to
5.4 g/dL)
Bring glucose normal range (<140 mg/dL as is normal for a diabetic)

NUTRITION MONITORING and EVALUATION
Timeframe for follow-up: follow up within 24hrs while in hospital, upon discharge follow up weekly with
dietitian at dialysis clinic

Monitor:
Electrolyte status
Blood glucose levels
Serum albumin levels
Adherence to medications