FN 125 - DIET THERAPY I Date Performed: February 27, 2014
Group No and Section: 1 HCDE Date Submitted: March 7, 2014
Group Members: Nature of Contribution:
Dela Cruz, Frances Mae SOAP, Introduction, Methodology,
Conclusion
SOAP, Results, Discussion, ATQ
Laganse, Rosevie Angelica
SOAP, Methodology, Results, Discussion,
Mingua, Jamin Ica ATQ
SOAP, Results, Discussion, ATQ
Soriano, Arah Pauline
PLANNING A RENAL DIET
Exercise No. 5
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SOAP Notes
Subjective The patient is Maritino Aguilar. He works as a carpenter and is already married
with a 12 year-old son. He currently resides in Fairview, Quezon City but his
hometown is in Sta. Maria, Bulacan.
Patient primarily complains easy fatigability. Three months prior to admission, he
was afebrile and had not felt any flank pains.He also experienced bipedal edema
and small frequent, tea-colored urination (polyuria) seconded by his attending
physician during his medical consultation.
Flank pains, poor appetite, and edema with ascites and periorbital edema were felt
by the patient two months prior to admission; while, easy fatigability, orthopnea
and paroxysmal nocturnal dyspnea started to compromise the condition of the
patient two weeks prior to admission.
Upon admission, the patients condition was initially managed. Patient said he
prefers vegetables and fish.
Objective He is 57 and weighs 130 pounds. Three months prior to admission, the patient
was prescribed with Lasix and Septrin for two months to relieve edema and
oliguria. Then, two weeks prior to admission, another doctor
prescribed Aldazide and Persantin, which did not improve his condition. While he
was admitted in the hospital, he was given Lasix, Calcibloc and Septrin to manage
his condition.
The patients urinalysis showed a specific gravity of 1.035 which is above the
normal range. The urine was yellow, turbid, acidic and very heavy in protein.
Sugar was also found in his urine, as well as red blood cells, pus cells and
epithelial cells. The renal cells present were rare and there are also a few
amorphous urates (salts of uric acid) present.
His blood chemistry, on the other hand, showed the following: albumin - 22 g/L,
cholesterol - 8.55 mmol/L, hemoglobin - 108 g/L, sodium - 128 mmol/L and
potassium - 6.5 mmol/L.
While his blood pressure was constant at 160/100, ranging from 100-170/60-110.
Assessment The patients BMI is 20.41 kg/m2 which make his weight normal for his height.
Based from the patients laboratory results, he has large amount of protein in his
urine and sugar, red blood cell casts, as well as pus cells are present. There are also
amorphous urates in his urine which are accumulated salts of uric acid. Also, the
patient has abnormal values for albumin, cholesterol, hemoglobin, sodium, and
potassium.
These laboratory results and physical manifestations such as edema, fatigability,
orthopnea, and dyspnea lead to the assessment that the patient has Acute
Glomerulonephritis or the inflammation of the glomerulus capillary loops. This
condition results to hypertension and edema as sodium and water are being
retained. Blood cells and proteins also are filtered as renal function is affected. The
patient may have obtained the condition because of streptococcal infection.
Plan A renal diet will be given to the patient. The diet prescription of one day meal plan
is Energy 2100 kcal, CHO 335 g, CHON 45 g, Fat 65 g, Na 2000 mg, K 2000 mg,
Ca 1400 mg, P 700 mg, Fluid 1500 ml. The dishes that are considered are based
from the food preferences though will not compromise the condition of the patient.
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Introduction
Keeping the bodys electrolytes, fluids and organic solutes in balance is the one of the major
functions of the kidneys. The nephrons, functional units of the kidneys in the renal cortex, are in-
charge of filtering most of the blood, reabsorbing the needed nutrients, maintaining the acid-base
balance and excreting wastes in the body. Most the wastes excreted by the kidneys go with the urine.
Urine formation consists of three basic processes: (1) glomerular filtration, (2) tubular secretion, and
(3) tubular reabsorption. Several disease conditions can interfere with these functions (Mahan
and Escott-Stump, 2008; Martini and Nath, 2009).
Acute Renal Failure is marked by a reduction in the glomerular filtration rate and a
modification in the kidneys ability to excrete metabolic wastes. Oliguria, which is the first phase of
Acute Renal Failure, is characterized by a decreased daily urine output of less than 400 mL
(hypouresis) which may last one to three weeks. Because of the decrease in urine output, more
nutrients such as sodium and water, and wastes are retained instead of being excreted out of the body.
People who are suffering from oliguria are more prone to have edema, uremia, metabolic
acidosis, hyperkalcemia, hypernatremia and hypocalcemia (Mahan and Escott-Stump,
2008; Nelms, et.al., 2007).
As aforementioned, a decrease in urine output could cause retention of nutrients such as
sodium and water. Another condition which is associated with oliguria is ascites. Ascites is the build-
up of fluids in the peritoneal cavity. As more fluids collect, abdominal pain and dyspnea may be felt,
and bloating may be seen. This is caused by a high blood pressure in the blood vessels and low
albumin levels in the body which may have resulted from an impaired kidney function (Macmillan
Cancer Support, 2013; Franz and Horl, 1997).
Diet plays a critical role in the care of patients with Acute Renal Failure Phase 1. In planning
an individualized renal diet for these patients, it is important to note the possibility of uremia,
metabolic acidosis, fluid and electrolyte imbalances, infection, and tissue destruction
(Nelms, et.al., 2007). By doing so, the diet which should be planned by the dietitian should be limited
in fluids, low in protein, adequate in energy and, restricted in salt, potassium, phosphorus and other
electrolytes (Mahan and Escott-Stump, 2008).
This exercise aimed to plan and prepare an individualized renal diet for Mr. Martino Aguilar
by relating his anthropometric measurements, laboratory results, medications and lifestyle.
Afterwards, the diet was evaluated for its nutrient content, palatability and costing.
Methodology
A diet prescription was made for Martino Aguilar, 43 years of age, wherein his
anthropometric, biochemical, and clinical assessments were considered. The subject weighs 130
pounds and his height is 5 feet and 7 inches. From these data, Body Mass Index (BMI) was
computed.
[Equation 1]:
Wt: 130 lbs/ 2.2= 59kg
Ht: 5 ft and 7 inches
= 5 ft x 12 inches/1 ft= 60 inches + 7= 67 inches
=67 inches x 2.54 cm/ 1 inch= 170.18 cm
BMI= wt (kg)/ ht (m)2 = 59/ 1.70182 = 20.37-> 20
The BMI of the subject is 20 hence normal based from Asia Pacific Classification. However
based from his clinical data, the patient has edema so his dry weight was also computed.
[Equation 2]:
Actual Weight: 130 lbs x 1 kg/2.2 lbs = 59.09 kg
Normal Total Body Water: 0.5 x 59 = 29.5 kg
Actual Total Body Wt.: 142 x 29.5/128= 32.7 kg
Estimated Body Water: 32.7-29.5 = 3.2
Dry Weight: 59- 3.2= 55.8 ~ 56 kg
For the dry weight, his actual body weight (130 lbs) was converted to kilograms in which
the resulting value is 59.09 kg. Normal total body water was obtained by multiplying this actual body
weight to 50%. For actual total body water;142 mmo/L is the average normal value of serum sodium
and it was divided to the actual serum sodium of the subject which is 128 mmol/L. The difference
between actual total body water and estimated body water was derived hence the resulting dry weight
is 56 kg. His BMI is classified as still normal based from Asia Pacific Classification.
[Equation 3]:
BMI= wt (kg)/ ht (m)2
= 56/ 1.70182 = 19.34 ~19
Dry weight was used in computing Total Energy Allowance through Tannhausers Method in
which his Desirable Body Weight (DBW) was initially obtained.
[Equation 3]:
Ht. = 5 ft and 7 inches
5 x 12=60 + 7= 67 inches
67 inches x 2.54= 170.18-100=70.18
70.18-7.018= 63.162
DBW= 63 kg
Total Energy Allowance:
63 kg (27.5 kcal/kg) = 1732.5-> 1750 kcal
The resulting kilocalorie was compared with the kilocalories that would be obtained from
Ireton Jones, Harris Benedict and Mifflin St. Jeor Equations. In these three equations, stress factor of
1.25 and activity factor of 1.2 were considered.
[Equation 4]:
Ireton Jones Equation
REE= 629- 11(Age) + 25 (Wt) 609 (0)
= 629-11(43) + 25 (56)- 609 (0)
=629-473 + 1400-0
= 1556 kcal (1.25) (1.2)
=2,334 kcal-> 2350 kcal
[Equation 5]:
Harris Benedict Equation
REE= 66.5 + 13.8(56) + 5(170.18cm)-6.8(43)
=66.5 + 772.8 +850.9-292.4
=1397.8 kcal (1.25) (1.2)
=2096.7kcal ~ 2100 kcal
[Equation 6]:
Mifflin St Jeor Equation
REE= (9.99 x 56) + (6.25 x 170.18 cm) (4.92 x 43) + 5
=1416.505 (1.25) (1.2)
=2124.75 kcal~ 2100 kcal
After computing the kilocalories, 2100 kcal was opted for meal planning which was from
Harris Benedict and Mifflin St. Jeor Equations. This kilocalorie was distributed among
macronutrients through Non Protein Calorie (NPC) method.
[Equation 7]
(0.80g/kg) (55.8)
44.64 g -> 45 g
CHON Calories 45 kcal x 4 kcal/g = 180 kcal
NPC Calories 2100-180= 1920
CHO and Fat Distribution: 80-20
CHO 1920 x 0.70/ 4= 336~ 340 g
Fat 1920 x 0.30/9= 64~ 65 g
Diet Rx: Energy 2100 kcal, CHO 335 g, CHON 45 g, Fat 65 g, Na 2000 mg, K 2000 mg, Ca
1400mg, P 700 mg, Fluid 1500 ml
Lower limit of protein (0.80 g/kg) was opted in computing protein
requirement. Carbohydrate and fat distribution was 80-20 percent of the rest of
kilocalories. Sodium, potassium, calcium, phosphorus and fluid were included in the prescription
since the subject was diagnosed with Acute Glomerulonephritis.
The diet prescription for the patient is the following: Energy 2100 kcal, CHO 335 g, CHON
45 g, Fat 65 g, Na 2000 mg, K 2000 mg, Ca 1400 mg, P 700 mg, Fluid 1500 ml. The Handbook for
Nutritional Management of Renal Disease of FNRI-DOST was used in meal planning. Initially, high
and low biological values of protein were computed as seen on the formula below.
[Equation 8]:
HBV CHON (High Biological Value of Protein)
=2/3 (45) = 30 g
LBV CHON (Low Biological Value of Protein)
=1/3 (45) = 15 g
After such, exchanges were distributed among food groups which later correspond to food
items that would be served for a particular meal pattern.
Table 1. The Number and Distribution of Exchanges
AM PM BT
Food Group No. of Exchanges Breakfast Lunch Dinner
Snack Snack Snack
Vegetable
3 1 - 2 - - -
Group A
Vegetable
2 - - - - 2 -
Subgroup A1
Fruit 3 1 - - 2 - -
Milk, powdered
0.5 - - - - - -
whole
Sugar 29 - 10 6 8 3 2
Rice 6 2 - 2 -
Meat 3 1 - 1 - 1 -
Fat 11 3 - 1 2 2 3
Three exchanges were allotted for vegetable group A, whereas two exchanges for vegetable
subgroup A1 which were mainly distributed under breakfast, lunch and dinner. As for fruits, only
three exchanges were allotted thus one exchange for breakfast and two exchanges for PM snack. Milk
is only one half exchange which is equivalent to two tablespoons of whole milk. Rice exchanges
were six in which two was allotted for breakfast and lunch while one half for dinner and bed time
snack. About twenty nine exchanges were designated for sugar hence food items under this category
are present in each meal pattern. For meat, three exchanges were evenly distributed under breakfast,
lunch and dinner and lastly for fat, there were eleven exchanges distributed among meal patterns
except for AM snack. With these, the one day menu is the following.
The diet prescription was then translated into exchanges and assigned for all the food
groups. After setting the number of exchanges for each food group, these exchanges were translated
among the six meals of the day namely; breakfast, AM snack, lunch, PM snack, dinner and bedtime
snack. With the exchanges already set and distributed for each meal for the whole day, a menu plan
was then formulated. The meals planned include Fried Bangus with Tomato Slices for
breakfast, Nata de Coco with Condensed Milk for AM snack, Ginisang Sayote with Pork Giniling for
lunch, Banana Cue for PM snack, Steamed Tilapia with Sauted Squash and String Beans for dinner
and lastly, Whole Milk and Toasted Bread for bedtime snack. Each ingredients of the meals included
in the menu were assigned with specific household measures in accordance to the number of
exchanges.
Breakfast
Fried Bangus
Tomato
Rice
Apple
AM Snack
Nata de Coco
Condensed Milk
Lunch
Ginisang Sayote
Rice
Polvoron
PM Snack
Banana Cue
Dinner
Steamed Tilapia
Sauteed Vegetables
Rice
Hard Candy
Bedtime Snack
Toasted Bread
Milk
A block recipe indicating the ingredients, amount in grams and household measure, and steps
in cooking was then created to serve as guide in cooking during the meal preparation. The important
nutrients and its function in the body were also included in the block recipe next to the column of
the ingredients. Appendix B shows the block recipe for the three main meals breakfast, lunch and
dinner. The block recipe for the snacks such as AM, PM and bedtime snack were no longer made
since those meals do not require long steps of cooking. A production schedule was also made to guide
the flow of preparation and meet the 10:40 am deadline of serving. See Appendix B.
However, during the wet laboratory, only the breakfast, lunch and dinner were prepared. Prior
to their preparation, the working station and all the equipment to be used were sanitized using hot
water. The ingredients were initially washed and cleansed of dirt. The members of the group in-charge
with the preparation also wore the proper personal protective equipment (PPE), plastic gloves and
face masks to ensure food safety.
During the preparation, mise en place was initially done. The fish, vegetables and fruits were
peeled and cut according to desired shape and size. All ingredients including the dry ingredients were
then weighed using the digital weighing scale according to the amounts indicated in the block
recipe. After everything is set, the chief cook helped by the housekeeper then proceeded with the
cooking as guided with the block recipe and production schedule.
While the chief cook and housekeeper were cooking, the dietitian was computing for the
nutrient content of the dishes prepared using Microsoft Excel. The formulas for computing the
nutrient content of the meals were already set in the said software and the dietitian just needed to
input the edible portion weight of the ingredients used in the food preparation. In addition, the
nutrient adequacy based on the Recommended Energy and Nutrient Intakes (RENI) for Filipinos and
based on the diet description were also computed for nutrients which were all presented in the results.
Computations were also done using Microsoft Excel. Lastly, the cost of the dish per meal and for the
whole day was also determined to know if the diet planned has fitted the 100-peso budget limit.
On Cooking the Dishes
Breakfast
In the preparation of the breakfast which was Fried Bangus, all the ingredients such as
tomatoes, onions and calamansi were first chopped. Then, the bangus was marinated with calamansi,
black pepper and a half teaspoon of salt. Afterwards, it was set aside for about 10 minutes and was
fried to golden brown in a minimum amount of vegetable oil. The fried bangus was drained of excess
vegetable oil. It was plated together with the boiled rice and sliced tomatoes and onions at the side.
Apple slices which were pre-soaked in water with acid were also included in the tray. The breakfast
contained 70 mL of fluids which is evidently seen in the glass of water which was served.
Lunch
The lunch which was Ginisang Sayote was cooked by first sauting the garlic and onions
followed by the ground pork. A minimum amount of 31 mL of water based on the 101mL fluid
allotted for lunch was then added to facilitate the simmering of the ingredients. Afterwards, the
chayote strips were added and were cooked until tender. No salt was used in the preparation of the
dish as it was substituted by soy sauce. Then, the dish was plated with boiled rice and was served with
two pieces of polvoron and 70 mL of drinking water on the tray.
Dinner
The dinner which was Steamed Tilapia with Sauteed Squash and String Beans was cooked by
first marinating the tilapia and boiling the water for the steamer. No salt was used in the preparation of
the steamed tilapia as this was substituted by herbs and spices such as black pepper, calamansi,
ginger, onion, tomato, lemongrass and dried rosemary. Afterwards, the marinated tilapia was wrapped
in an aluminum foil and was steamed for 30 minutes.
For the preparation of sauted squash and string beans, garlic and onion were
first sauted until brown. Then, the squash and string beans were simmered together until soft, with
the fish sauce and 30 mL of water based on the 100 mL fluid allotted for dinner. Before plating, the
steamed tilapia was unwrapped from the aluminum foil. It was plated together with boiled rice
and sauted squash and string beans at the side. Accompanying this on the tray are three pieces of
Max cherry-flavored candies and 70 mL of drinking water.
Results
On the Nutrient Content
The nutrient content of the meals were computed as seen on Table 2. These correspond to
the nutrients found in Handbook for Nutritional Management of Renal Disease (FNRI-DOST,
2008).
