JP Slovack B.

Patient Narrative

NTR 517/417 NTR Care Plan

Social History Mrs. S lives with her husband, both who have full-time job. They have adequate funds for food and shelter. Mrs. S is currently out of work on short-term disability following two surgeries on her kidneys to remove multiple, impacted kidney stones. She had a catheter placed between the two surgeries, which impeded her activities of daily living, but it has since been removed. Prior to the surgery both her and her husband would cook dinner and shop for groceries, but she has since done most of the cooking while her husband has done most of the grocery shopping. She has no current history of alcohol use. She used to smoke ~1 pack/per day for 10 years, but quit 28 years ago. Nutritional Implications: Mrs. S has a very supportive husband and ever since she had her catheter removed following the second surgery, she has been able to resume many of her activities of daily living. She currently relies on her husband for travel, as she cannot drive due to her medication. Due to this, she is dependent on her husband for weekly appointments to the doctors office while she has been recovering. After her first surgery, she had a home nurse come in every 3-4 days to clean/change her bandages and the catheter. Medical History Mrs. S was diagnosed with hypertension three years ago. She has had mild cases of anxiety, on and off for four years. She has complained about frequent bouts of heartburn for the past year and was diagnosed with a hiatal hernia three months ago. Approximately two months ago she was rushed to the emergency room complaining of intense lower back pain where she found to have over 12 impacted kidneys stones in both sides of her kidneys. She had an initial hospital stay of four days where all the stones were removed from the right side kidney, and the largest stones removed from the left kidney. Due to the extreme number of stones observed in the left kidney, a stent was placed and a follow-up surgery scheduled. During the second surgery the remaining stones from the left side were removed. Her stones were of the calcium oxalate variety. Nutritional Implications: Mrs. S has expressed anxiety of eating certain foods for fear of having additional kidney stones formed. Confusion over what foods to eat may also affect her enjoyment of eating, as she feels she should not be consuming certain foods that have a stigma of causing kidney stones such as dairy products, chocolate, coffee and tea. Diet History Mrs. S is currently consuming a normal diet of meals and snacks (three meals and two snacks/day) and reports that she has a good appetite. She is not currently following any special diet, but as mentioned, has been hesitant to consume certain foods (dairy, tea) out of fear of future kidney stone formation. She has been trying to lose some weight though, and has tried to reduce her overall caloric intake. Mrs. S states that she does not take any vitamin or mineral supplement and believes she is lactose-intolerant.

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NTR 517/417 NTR Care Plan

Nutritional Implications: Her three-day dietary recall shows an average consumption of 1299 kcal/day kcal per day, along with 64 g of protein per day. Her diet shows an inadequate intake of calcium, potassium, vitamin D and magnesium. According to her dietary recall she is consuming only 17% of her kcal/day from fat, as opposed to the recommended 20-35%. Medications Lisinopril ACE inhibitory being used to treat Mrs. Ss high blood pressure. Nutritional Implications: This drug can be taken without regard to food. It may increase serum potassium levels. Caution should be used with salt substitutes or a high potassium diet. Patient should insure adequate fluid intake/hydration Lortab - opioid-based analgesic (pain killer) used to treat pain from the kidney stones and surgery Nutritional Implications: Should take with food or milk to reduce GI distress. Can delay digestion and cause constipation and/or dry mouth. Should also avoid alcohol while taking this drug. Paxil Antianxiety medication used for Mrs. Ss anxiety Nutritional Implications: Should avoid alcohol. This drug may alter appetitie and change taste perception, specifically reducing sweet perception and reduce bitter threshold

C. PATHOPHYSIOLOGY Mrs. Ss problems consist of hypertension, acid reflux and recovery from her kidney stone removal surgery. Currently, she is most concerned with preventing any future reoccurrence of kidneys stones, specifically calcium oxalate stones. As kidney stones have a high recurrence rate (Mahan, Raymond and Escott-Stump, 2013) preventing additional kidney stones is an extremely important health concern for Mrs. S and will therefore be the focus of this discussion. Kidney stones are pieces of aggregated solids that can form in very concentrated urine (source). The presence of kidney stones, medically known as nephrolithiasis, is a substantial health concern in the United States. It occurs in more men than women, most frequently between 30 and 50 years of age (Mahan, Raymond and Escott-Stump, 2013). The current ratio between men and women are approximately 1.3:1, mostly due to the increasing frequencies of obesity, diabetes and metabolic syndrome in women, evening out the ratio (Mahan, Raymond and EscottStump, 2013). Kidney stones cause approximately one million visits to doctors offices and 300,000 trips to an emergency facility each year (US Department of Health, 2013). Kidney

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NTR 517/417 NTR Care Plan

stones are estimated to have affected 8.8% of the American population. (US Department of Health, 2013). Nephrolithiasis is a very complicated and complex process. Stone formation follows the steps of saturation, supersaturation, nucleation, crystal growth and aggregation, crystal retention and finally formation of the stone. The binding, aggregating and growing of stones creates stones of varying size that can become lodged in the kidneys producing blood, pain, reduced urine or an infection (Heilber and Goldfarb, 2013). The most common type of stone is a calcium stone which compromise over 70% of all kidney stones, with the most common type of calcium stone being a calcium oxalate stone, which makes up 60% of all kidney stones. Other types include calcium phosphate, uric acid, struvite and cystine (Mahan, Raymond and Escott-Stump, 2013). Anybody is at risk for kidney stone formation (Mahan, Raymond and Escott-Stump, 2013). Those at risk often experience hypercalciuria, where abnormally large amounts of calcium end up in the urine. Family history of kidney stones or kidney conditions such as cystic kidney disease can also increase the potential for a stone formation (Mahan, Raymond and EscottStump, 2013). Other risk factors include hyperparathyroidism, acidic urine, hyperxaluria (high oxalate content in urine), gout, obesity, diabetes, and glucocorticoid use (Mahan, Raymond and Escott-Stump, 2013). Those with calcium stones often have high urine levels of calcium, a condition that may not have an underlying cause and may affect bone health should the patient restrict calcium too much (Mahan, Raymond and Escott-Stump, 2013). Calcium oxalate stones can have a genetic basis, but have both a high occurrence and recurrence rate, especially those who have fat malabsorption diseases where increased bile retention in the GI tract causes the intestines to become more permeable to oxalate and in effect, absorb more (Heilber and Goldfarb, 2013). Kidney Stones are diagnosed with via a urine analysis, ultrasound, CT scan, x-ray or blood test. For the imaging techniques (ultrasound, CT scan and x-ray) the healthcare provider is looking for physical evidence of the stones, while the biochemical tests are looking for conditions related to kidney stones such as an infections in urine or high calcium levels (US Department of Health, 2013). Treatment of kidney stones depends greatly on their size, composition and location. Small stones may pass freely on their own, with increased fluid intake and medication (US Department of Health, 2013). Larger stones though often times get stuck and require surgical intervention. One method is utilizing a lithtriper, which generates shockwaves, breaking the stone into smaller, more passable pieces (US Department of Health, 2013). Other methods, such as percutaneous nephrolithotomy and ureteroscopy, physically remove the stone either through the back (neprolithotomy) or the ureter (urteroscopy) (US Department of Health, 2013). Nutrition therapys role in nephrolithiasis revolves around prevention of kidney stone formation, especially prevention of recurrence. The most beneficial revolves around increased urine output, at least 2 to 2.5 L per day (Mahan, Raymond and Escott-Stump, 2013). The less concentrated the urine, the less likely it is form nucleation and aggregation of solutes. Up to 3L of fluid per day may be necessary to account for fluid loss from GI issues, sweating, exercise and so forth (Mahan, Raymond and Escott-Stump, 2013). For prevention of calcium oxalate stones, it was originally advised for patients to reduce calcium. This was found to have an increased correlation with stone formation and has since been discontinued. Current recommendations include

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NTR 517/417 NTR Care Plan

consuming 800 1200 mg of calcium per day, reducing sodium levels to decrease calcium excretion, and increasing potassium intake (Heilber and Goldfarb, 2013). A diet low in animal protein may also decease calcium excretion, by increasing the pH of the urine (Mahan, Raymond and Escott-Stump, 2013). A key component to reduce the risk of calcium oxalate stones revolves around pairing calcium and oxalate foods, while reducing high oxalate foods such as rhubarb, spinach, strawberries, chocolate, beets to lower total oxalate consumption 60 mg/day (Mahan, Raymond and Escott-Stump, 2013). Pairing calcium and oxalate foods allow calcium to bind oxalate in the intestine, increasing the elimination of oxalate via the GI tract and not the kidneys (Heilber and Goldfab, 2013). ASSESSMENT: Mrs. Ss main concern involves preventing future kidney stone formations. Her stones were calcium oxalate stones, and because of this, her dietary history was evaluated for guidelines consistent with reducing kidney stone formation. The main focus therefore will be on evaluating the patient fluid intake, weight, calcium intake, oxalate intake, sodium intake, potassium intake and protein intake. Mrs. S dietary recall showed greater than 2 L of fluid consumed. Recommendations include increasing urine output to at least 2 L to reduce the concentration of urine. No adjustments appear to be needed at this time. Mrs S should be encouraged to also drink water before going to bed to prevent concentrated urine in the morning. Her dietary recall also shows consumption of some high oxalate foods such as tea, strawberries and chocolate. Mrs. S should avoid high oxalte foods, while choosing lower oxalate foods and consuming them at the same time as as calciumrich foods. Mrs. Ss dietary recall shows ~561 mg of calcium consumed which is well below the recommended 1200 mg per day for individuals over the age of 50. Low calcium intake is associated with higher stone formation risk. Due to this Mrs. S should be encouraged to consume calcium at each meal to increase her calcium intake as well as to reduce the risk of osteoporosis. A calcium supplement is not advised, as it is not associated with the stone forming protective benefits from food. Another mineral Mrs. S was low in was potassium (2300 mg compared to recommended intake of 4700 mg). Her sodium intake was 1678 mg, which is inline with recommendations to reduce total sodium intake to less than 2000 mg to prevent increase calcium excretion. Mrs. Ss current weight is 160 lbs which is greater than her ideal body weight of 120 pounds (133% IBW). Her caloric needs as calculated by the Mifflin St. Jeor equation with a 1.2 activity factor is 1547 kcal/day. Her BMI is 27.4, indicating overweight status. Overweight individuals have higher risk of developing kidney stones and so Mrs. S should be encouraged to at least maintain her current weight and ideally decrease her weight. Her dietary analysis indicates an average caloric intake of 1299 kcal/day. If continued, Mrs. S would be estimated to lose ~ pound per week on this reduced calorie diet. Based upon this assessment, the current nutrition diagnosis include

JP Slovack

NTR 517/417 NTR Care Plan

Inadequate calcium and potassium intake related to food and nutrition related knowledge deficit concerning kidney stone formation as evidenced by average calcium intake of 561 mg/day (recommendation = 1200 mg/day) and potassium intake of 2300 mg/day (recommendation = 4700 mg/day) Undesirable food choices related to food and nutrition related to knowledge deficit concerning kidney stone formation as evidenced by consumption of high oxalate foods (strawberries, chocolate, black tea, lentil soup). PLAN: Short-term Goals 1. Increase dietary intake of calcium to at least 800 mg/day and potassium to 3300 mg/day within 7 days 2. Eliminate High Oxalate foods (strawberries, chocolate pudding, black tea, lentil soup) and replace with moderate level oxalate foods (banana, vanilla pudding, herbal tea, tomato soup) within 7 days.

Long-term Goals 1. Increase calcium intake to recommended level of 1200 mg/day and potassium to recommended level of 4000 mg/day within 3 months (keeping potassium slightly lower due to lisinopril medication) 2. Reduce total oxalate consumption to less than 60 mg/day within three months. IMPLEMENTATION: 1. Encourage Mrs. S to include an alternative dairy product containing at least 250 mg of calcium at each meal to increase calcium intake (ie at least cup of lactaid/lactose-free milk at each meal) 2. Identify high potassium foods for Mrs. S to include in diet to increase potassium intake. (Educational handout: http://www.kidney.org/atoz/content/potassium.cfm). Cross reference list with high oxalate foods to avoid adding high oxalate foods to diet. Examples include Bananas, avocados, broccoli, brussel sprouts, milk). 3. Educate Mrs. S on oxalate content of foods, focusing on high oxalate foods as foods to avoid (Educational handout: http://www.ohf.org/docs/OxalateContent092003.pdf ). Examples include avoiding spinach, rhubarb, swiss chard, strawberries, beets, black tea, chocolate, lentils) Monitoring and Evaluation:

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NTR 517/417 NTR Care Plan

1. Evaluate dietary recall for intake of alternative dairy product at each meal (at least one/meal) 2. Evaluate dietary recall for total intake of calcium and potassium (for criteria see Goals above) 3. Evaluate dietary recall for consumption of high oxalate foods (for criteria see Goals above) REFERENCES Heilberg, I. P., & Goldfarb, D. S. (2013). Optimum nutrition for kidney stone disease. Advances in chronic kidney disease, 20(2), 165-174. Mahan, L. K., Raymond, J. L., & Escott-Stump, S. (2013). Krause's food & the nutrition care process. Elsevier Health Sciences. U.S. Department of Health and Human Services, The National Kidney and Urologic Diseases Information Clearinghouse (2013). Kidney stones in adults (132495). Retrieved from NKUDIC website: http://kidney.niddk.nih.gov/kudiseases/pubs/stonesadults/