Patient Nutritional Assessment and Recommendations

Abstract

This nutritional assessment focuses on the idea of how a patient’s diet can directly impact their health and any disease processes they may have. It will first explore the daily diet of a patient who is currently admitted into a hospital. The assessment of the patient’s daily diet will include what type of food the patient eats, the amount they eat, the percentage of carbohydrates, fats, and protein contained in the food, the amount of electrolytes, and the amount of vitamins. After this is established, the paper will also describe the ideal diet for the patient based on their diagnosis and comorbidities. Equating the typical patient’s diet to the ideal diet, any modifications or recommendations that should be made to the diet will be explained.

Nutritional Assessment

Although many people are told from a young age to eat their vitamins and minerals, this can often be neglected. Negligence can be due to a variety of reasons such as having a demanding lifestyle, not being able to afford quality groceries, or by simply accommodating to the convenience of eating out. The majority of people tend to ignore how nutrition can play a vital role in preventing diseases or preventing a disease’s progression. This paper will look at how a patient’s diet impacts their current disease and comorbidities and any modifications they can make to improve their quality of life.

Typical Day’s Diet

VC is an 82-year-old diabetic male admitted to the hospital for hydronephrosis. In a typical day, he eats two packets (354g) of Quaker Instant Oatmeal. He cooks the oatmeal with two cups of Nestle PureLife Water. In addition to this, he also eats one Thomas’ Plain Bagel (95g) with four tablespoons of JIF Creamy Peanut Butter (66g). For a snack, he has one Mini Oreos Snak Pak (30g) and two cans of Pepsi (714g). Throughout the day my patient drinks eight to ten cups (64-80 fl oz) of water. For dinner, the patient eats at the Fiesta Buffet. VC claims he gets one cup (155g) of carrots and one cup (91g) of broccoli. Along with the veggies he gets half a cup (113.3g) of chicken with half a cup (130g) of shrimp. He gives this food to the Mongolian barbeque chef to cook with one forth cup (32g) of soy sauce.

Nutritional Components of Diet

Based on the 2,000-calorie diet, VC’s nutritional components were found on nutrionix.com, a database that gives information on grocery items, restaurant items, and common foods. The database is also in compliance with the Global Standards 1 (2019). The nutritional components of the oatmeal VC consumes every morning are the following: 14% carbohydrates, 7% fat (4% of saturated fat, 0g of trans fat, 1.5g of polyunsaturated fat, 1.4g of monounsaturated fat), 7% sodium, 6% potassium, 22% calcium, 118% iron, 24% of dietary fiber, 30% vitamin A, 1.6g of sugar, and 8.4g of protein (Nutrionix, 2019). The nutritional components of the plain bagel VC consumes every morning are the following: 2% fat (3% saturated fat, 0g trans-fat) 19% sodium, 2% potassium, 18% carbohydrates, 8% dietary fiber, 0.8% calcium, 16% iron, 6g sugar, and 9g of protein (Nutrionix, 2019). The nutritional components of the peanut butter VC consumes every morning are the following: 49% fat (35% saturated fat, 0g trans-fat) 12% sodium, 11% potassium, 5% carbohydrates, 16% dietary fiber, 6g of sugar, 14g of protein, 2.6% of calcium, and 11.2% iron (Nutrionix, 2019). The Mini Oreo Snak Pak VC eats contains the following nutritional components: 9% fat (10% saturated fat, 0g trans-fat), 6% sodium, 7% carbohydrates, 4% dietary fiber, 12g of sugar, 1g of protein, 2% calcium, and 8% iron (Nutrionix, 2019). The two cans of Pepsi VC consumes a day have the following nutritional component: 0% fat, 3% sodium, 27% carbohydrates, 82g of sugar and 0g of protein (Nutrionix, 2019). The carrots VC eats for dinner consists of the following: 9% of fat (4% of saturated fat, 0g trans-fat, 0.7g polyunsaturated fat, 4g of monounsaturated fat) 24% sodium, 14% potassium, 5% carbohydrates, 17% dietary fiber, 7g of sugar, 1.4g of protein, 492% vitamin A, 18% vitamin C, 4% calcium, and 3.3% iron (Nutrionix, 2019). The broccoli VC eats contains the following: 1% fat (0g of saturated, trans, polyunsaturated, and monounsaturated fat), 1% sodium, 8% potassium, 2% carbohydrate, 10% dietary fiber, 1.5g of sugar, 11% vitamin A, 135% vitamin C, 3.3% calcium, and 3.7% iron (Nutrionix, 2019). The chicken VC eats contains the following: 23% fat (21% saturated fat, 3.2g polyunsaturated fat, 5.9g monosaturated fat), 36% cholesterol, 3% sodium, 7% potassium, 26.7g of protein, 13.3% vitamin A, 0.8% vitamin C, 1.1% calcium, and 10.1% iron (Nutrionix, 2019). The shrimp VC eats contains the following: 43% fat (20% saturated fat, 0g trans-fat, 3.2g of polyunsaturated fat, 20g of monounsaturated fat), 37% cholesterol, 32% sodium, 6% potassium, 3% carbohydrates, 1g of dietary fiber, 2.3g of sugar, 12g of protein, 9.5% vitamin A, 15% vitamin C, 5.5% calcium, and 4.3% iron (Nutrionix, 2019). Lastly, the soy sauce VC consumes contains the following: 0% fat, 153% sodium, 1% carbohydrate, and 8g of protein (Nutrionix, 2019).

Recommended Diet Based on Pathophysiology

Pathophysiology

In order to understand what kind of diet is ideal for VC, one must understand the admission diagnosis. Hydronephrosis occurs when the kidneys enlarge due to the accumulation of urine; the buildup is caused by an obstruction (tumors, stones, trauma, structural defects, scar tissue, or fibrosis) in the renal pelvis or the proximal calyces (Ignatavicius, Workman & Rebar, 2016). The urine buildup also causes the renal pelvis or proximal calyces to dilate and increase in hydrostatic pressure; this combination causes the kidney to decrease its glomerular filtration rate, thus the kidneys reabsorbs waste materials that should be excreted in urine. Examples of waste products are excess water and excess electrolytes. Over time the vascular system of the kidney and the renal tubules can be damaged permanently (Huether & McCance, 2017).

Recommended Diet

Once the obstruction and excess fluid is removed from VC kidneys, it is essential for VC to follow a renal diet in order to preserve his renal tubules and the kidney’s vascular system from further damage. One of the first items a renal diet limits is the intake of sodium. A higher consumption of sodium pulls water into the body— limiting the sodium decreases fluid buildup in the body and lowers blood pressure (Centers for Disease Control and Prevention, 2019).  The decrease in fluid buildup and blood pressure allows the glomerulus in the kidneys to work with minimal stress, preserving the structure (VanPutte, Regan & Russo, 2017). According to the American Association of Kidney Patients, sodium intake should be limited to about 1,500-2,000 mg (2012). Foods such as pickles, soy sauce, butter, crackers, potato chips, processed meats, cheese, and canned goods contain high sodium levels, and should be avoided (Grodner, Escott-Stump & Dorner, 2016). Foods such as green vegetables, starchy vegetables, fresh fruits, fish, unsalted popcorn, unsalted nuts, and homemade soups are low in sodium and may be added to the diet (Grodner et al., 2016).

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The second item a renal diet limits is the intake of protein. This is due to the fact that the kidneys’ glomerulus has a harder time filtering out protein since it is a larger macromolecule. The strain of filtering a larger macromolecule can lead to further damage to the kidneys’ vascular system and calyces. Protein metabolism can also lead to an abundance of the following byproducts: ammonia, urea, nitrogen and sulfuric acid, thus giving the kidneys a higher amount of waste to filter out of the blood. Putting more strain on an already impaired organ can also lead to a decrease in renal function (Ignatavicius et al., 2016). The recommended amount of protein is 0.7g/1 kg/day. VC recommended amount of protein results in 77g of protein per day (Grodner et al., 2016). It is recommended to consume high-quality fish, poultry, and nuts (such as almonds and peanuts) to fulfil the body’s protein needs; however, processed meats, such as ham, bacon, sausages, and jerky, should be avoided (Grodner et al., 2016).

The third item a renal diet may limit is potassium and phosphorous. If VC’s kidney damage is extensive and limited in filtering blood, a high intake of potassium and phosphorous will lead to hyperkalemia or hyperphosphatemia (Grodner et al., 2016). Hyperkalemia is when the blood potassium levels exceed 5 mEq/L and can cause the following to happen: bradycardia, hypotension, cardiac arrest, muscle twitching, cramps, paresthesia, paralysis, nausea, and diarrhea (Ignatavicius et al., 2016). Foods that are high in potassium—e.g. apricots, avocado, bananas, squash, and dates—should be avoided. Foods that are low in potassium—e.g. apples, alfalfa, sprouts, asparagus, broccoli, black berries, blue berries, and celery—can be added to the diet (Grodner et al., 2016). Hyperphosphatemia is when blood phosphate levels exceed 4.5 mg/dL and causes the body to absorb an inadequate amount of calcium. The lack of calcium can lead to the following: painful tonic muscle spasms, cramps, tetany, laryngeal spasms, numbness and tingling of hands/toes/lips, seizures, diarrhea, abnormal blood clotting, and arrhythmias (Ignatavicius et al., 2016). Foods and beverages such as dark sodas, cocoa, cheese, oysters, and beef livers are high in phosphorous and should be avoided. Items such as fish, lamb, apple juice, grapes, and rice cakes are lower in phosphorous and can be added to the diet (Grodner et al., 2016). The decision to limit potassium and phosphorous must be determined by the physician and registered dietician after various renal tests are conducted (Grodner et al., 2016).

VC does have type II diabetes and will need to watch his intake of sugars along with following the renal diet. The average blood glucose range is 74-106 mg/dL. If the blood sugar drops below this, hypoglycemia occurs; if the blood sugar is higher than this, hyperglycemia occurs (Ignatavicius et al., 2016). The main concern with the diabetes and kidney damage is hyperglycemia. This is due to the fact that when the blood sugar is elevated for a long period of time, plaque formation will occur, and the diameter of the body’s vascular system will narrow. The narrowing can increase the risk for a blockage to ensue, which can result in another episode of hydronephrosis (VanPutte et al., 2017). In addition to this, the kidneys are strained trying to filter the excess amount of sugar in the blood; even though sugars are not the largest macromolecule, it can cause permanent damage to the glomerulus (VanPutte et al., 2017). Glycosuria can occur with hyperglycemia; this means sugar is found in the urine and leaves the body at risk for a urinary tract infection. If the patient were to get a urinary tract infection and it traveled to the upper urinary system, it can cause permanent damage the kidney (VanPutte et al., 2017). The excess amount of sugar can also damage the neurons in the body. If the neurons that innervate the bladder are damaged and the body is unable to excrete urine, the buildup of urine can cause pressure that will further damage the kidney (VanPutte et al., 2017). Foods and beverages to avoid are sodas, lemonades, energy drinks, white bread, pasta, white rice, flavored yogurt, honey, agave, dried fruits, potatoes, and fruit juices. Foods and beverages such as unsweetened tea, lean meats, plant-based protein, steel cut oatmeal, root vegetables, lentils, and quinoa can be added to the diet (Grodner et al., 2016). Depending on the patient and their severity of their disease, 35-77g of sugar can be consumed a day (VanPutte et al., 2017).

Comparison of Diets and Modifications

One of the main items VC should limit in his diet is his sodium. As mentioned previously, the recommended sodium intake is 1,500-2,000mg. The foods that VC consumes contains the following levels: 174mg of sodium in the oatmeal, 450mg of sodium in the bagel, 280mg of sodium in the peanut butter, 135mg of sodium in the Mini Oreo Snak Pak, 60mg of sodium in the cans of Pepsi, 574 mg of sodium in the carrots, 30mg of sodium in the broccoli, 80mg of sodium in the chicken, 770mg of sodium in the shrimp, 3,680mg of sodium in the soy sauce (Nutrionix, 2019). All this adds up to 6,233mg of sodium in one day, more than tripled the recommended amount. One of the main contributors to VC’s sodium intake is the soy sauce. Low sodium soy sauces like the brand Southern Tsunami can bring the sodium from 3,680mg to 1,040mg (Nutrionix, 2019). VC can also limit the amount of soy sauce he uses from 4 tablespoons to 2 tablespoons; this, in combination with using low sodium soy sauce, can bring his sodium intake for this item from 1,040mg to 520mg (Nutrionix, 2019). The next item that contributes to VC sodium intake is shrimp. The shrimp should be replaced with a healthier alternative such as fish. For example, a medium tilapia (170g) contains only 95mg of sodium. The bagels VC eats contains 450mg of sodium. VC can change the bagel and eat a slice of bread instead. Low Carb Bread contains 110mg of sodium per slice (Nutrionix, 2019).  VC can also replace the peanut butter he eats with almond butter. Four tablespoons of Member’s Mark Almond Butter contains only 4.4mg of sodium (Nutrionix, 2019). If VC were to use two tablespoons of low sodium soy sauce, eat tilapia instead of shrimp, eat a slice of bread instead of a bagel, and eat four tablespoons of almond butter, his sodium would be within the recommended amount at 1,782.4mg a day (Nutrionix, 2019).

In addition, the next item VC should limit is his protein. Currently, his protein consumption includes the following: 8.4g of protein of protein in his oatmeal, 9g of protein in the bagel, 14g of protein in the peanut butter, 1g of protein in the Mini Oreos Snak Pak, 1.4g in the carrots, 26.7g in the chicken, 12g in the shrimp, and 8g in the soy sauce (Nutrionix, 2019).  All these items equal 80.5g of protein a day. As mention before, the recommended protein a day is 77g a day.  Although VC is only 3.5g over his recommended amount, it is ideal to give the kidneys as much relief as they can get. If VC were to follow the modifications in his sodium intake, it would also lower his protein intake. The slice of low carb bread contains 2g of protein, four table spoons of almond butter contains 13.6g of protein, and two tablespoons of the low sodium soy sauce contains 2g of protein (Nutrionix, 2019). All these equals 73.1g of protein, just 3.9g of protein under the recommended amount. VC can also add almonds to his diet as a snack; 15-16 almonds can yield 3.8-4g of protein and can help VC reach his recommended protein intake (Nutrionix, 2019). 

The last item VC should limit is his sugar. The sugar he eats are in the following foods: 1.6g in the oatmeal, 6g of sugar in the bagel, 6g of sugar in the peanut butter, 12g of sugar in the Mini Oreo Snak Pak, 82g of sugar in the cans of Pepsi, 7g of sugar in carrots, 1.5g of sugar in the broccoli, and 2.3g of sugar in the shrimp (Nutrionix, 2019).   All these equals 118.4g of sugar in one day. The severity of VC diabetes is unknown, however, the normal range for males is usually between 25-77g of sugar consumption a day (VanPutte et al., 2017). If VC were to make the previous changes for the sodium and protein intake, the slice of low carb bread yields 1.1g of sugar, the four tablespoons of almond butter yields 2.8g of sugar, the medium tilapia yields 0g of sugar, and the two tablespoons of low sodium soy sauce yields 2g of sugar (Nutrionix, 2019). All this equals 110g of sugar, which is still over the recommended value. If VC were to cut out both cans of Pepsi, it would bring his sugar consumption down to 28g of sugar a day. In order to prevent hypoglycemia, VC can incorporate Fuji apples into his diet. One medium Fuji apple (192g) contains 22g of sugar (Nutrionix, 2019). This allows VC to eat one to two apples a day to control his blood sugar. Since the damage of VC’s kidneys are unknown, limiting phosphorous and potassium levels are to yet be decided and will not be discussed.

Conclusion

 In conclusion, an individual’s diet can play an imperative role in preventing diseases, managing current diseases, and refining one’s quality of life. In VC’s case, modification to his current diet will assist in the control of both his diabetes and preserving his kidney function. Even though some people are inclined to overlook their nutrition for a myriad of reasons, nurses ought to take the time to educate their patients on the importance of nutrition and the various resources available one can use to modify their diet.

References

Centers for Disease Control and Prevention. (2019). Diabetes and kidney disease: What to eat. Retrieved from https://www.cdc.gov/diabetes/managing/eat-well/what-to-eat.html.

Grodner, M., Escott-Stump, S., & Dorner, S. (2016). Nutritional foundations and clinical applications: A nursing approach. St. Louis, Missouri: Elsevier Mosby.

Harum, P. (2012). APKP nutrition counter: A reference for kidney patients. [PDF file]. Tampa, Florida: AstraZeneca. Retrieved from http://157.230.4.232/wpcontent/uploads/ woocommerce_uploads/2016/10/NutritionCounter_English_080618_digital.pdf.

Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology. St. Louis, Missouri: Elsevier.

Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2016). Medical-surgical nursing: Concept for interprofessional collaborative care. St. Louis, Missouri: Elsevier.

Nutrionix. (2019). Consumer tools. Retrieved from https://www.nutritionix.com/.

                 VanPutte, C., Regan, J., & Russo, A. (2017). Seeley’s anatomy and physiology. New York, New York: McGraw Hill Education.