Renal and DM2 Case Study Patient Data Mrs. Sara Bellum DOB: 03/28/1958 New Mexico State University Dietetic Internship Anthropometrics Diet Labs Meds Intake Height: 5'3" Consistent GFR: 10 ml/min Glucotrol Weight: 142 lbs Carbohydrate/Renal BUN: 33 mg/dL Dyrenium 70% of tray diet Creatine: 2.5 mg/dL Cardura 900-1100 mL/day Renagel Referral Referred to RDN in ACES dialysis clinic Case Study Brief You conducted a nutritional assessment on this patient a couple of days ago and agreed on a discussion about a dialysis and diabetes diet. Now, provide an in- depth protein and fluid education to the patient. You will need to know: Protein sources Amount to eat daily Protein and other foods high in phosphorus (I.e. cheese, legumes) Cooking method of protein sources Urine produced daily Dividing fluids throughout the day Types of fluid Acceptable fluids (l.e. ginger ale) Fluids to avoid (l.e. dark colas) Food considered fluid (l.e. jello) Tips to reduce thirst Steps Case Study Flow Knock on door and ask permission to enter room Greet patient by name Introduce yourself Identify patient by two patient identifiers State purpose of visit Give patient protein and fluid education Mention further education at next dialysis session Give the patient a renal diabetic dietic booklet Note You must motion a knock on the virtual door I.e. Mrs. Bellum Full name and DOB will be used for virtual reality case studies The RD will provide this for this case study These can be done in any order Sodium, potassium, and phosphorus Give the patient an idea of what Blood sugars, carbohydrates, sample meals to expect next session Ask if the patient has any questions Thank the patient A-Assessment 5/06/2020 Reason for Nutrition Assessment: 62 YOF REFERRED TO RDN IN ACES DIALYSIS CLINIC FOR CONSISTENT CARBOHYDRATE/RENAL DIET EDUCATION Client History (CH): note which diagnosis is the primary or admitting diagnosis CH-2.1.1 CH-1.1.1 CH-1.1.3 CH-1.1.4 CH-1.1.6 Patient chief nutrition complaint: PT IS TIRED (PT IS ON HEMODIALYSIS) Age: 62 Sex: FEMALE Race: CAUCASIAN Language: ENGLISH Patient/Client/Family Medical/Health History: CH-2.1.1 CH-2.1.3 Patient chief nutrition complaint: PT IS TIRED (PT IS ON HEMODIALYSIS) Endocrine/metabolism: DM2 DIAGNOSED 5 YEARS AGO Social History: CH-3.1.2 CH-3.1.4 COOK CH-3.1.5 Living/housing situation (specify): LIVES WITH HUSBAND Social and medical support (specify): HUSBAND DOES THE COOKING WHEN PT IS TOO TIRED TO Geographic location of home (specify): LAS CRUCES Anthropometric Measurements (AD): AD-1.1.1.7 Stated Height: 160 CM (5'3") AD-1.1.2.16 Postdialysis weight: 64.4 KG (142#) AD-1.1.5.1 BMI: 25.2, OVERWEIGHT Nutrition Focused Physical Findings (PD): PD-1.1.5 PD-1.1.9.2 Vital signs: Digestive system: PT WITH FAIR APPETITE Anuria: PT REPORTS PRODUCING URINE "MAYBE TWO OR THREE TIMES A DAY" PD-1.1.21.5 PD-1.1.21.6 PD-1.1.21.7 Pulse rate: 85 BPM Respiratory Rate: 13 BREATHS PER MINUTE Temperature: 37 CELSIUS Food/Nutrition Related History (FH): FH-1.2.1.1 FH-1.2.2.1 FH-1.2.2.2 FH-1.2.2.3 FH-2.1.1.2 Oral fluid estimated intake in 24 hours: 900-1100 ML FLUID/DAY Estimated amount of food: 70% OF TRAY Types of food/meals: PRE-SELECT MENU Meal/snack pattern: 3-5 MEALS PER DAY AT HOME Modified diet order: CONSISTENT CARB/RENAL DIET

Renal and DM2 Case Study Patient Data Mrs. Sara Bellum DOB: 03/28/1958 New Mexico State University Dietetic Internship Anthropometrics Diet Labs Meds Intake Height: 5'3" Consistent GFR: 10 ml/min Glucotrol Weight: 142 lbs Carbohydrate/Renal BUN: 33 mg/dL Dyrenium 70% of tray diet Creatine: 2.5 mg/dL Cardura 900-1100 mL/day Renagel Referral Referred to RDN in ACES dialysis clinic Case Study Brief You conducted a nutritional assessment on this patient a couple of days ago and agreed on a discussion about a dialysis and diabetes diet. Now, provide an in- depth protein and fluid education to the patient. You will need to know: Protein sources Amount to eat daily Protein and other foods high in phosphorus (I.e. cheese, legumes) Cooking method of protein sources Urine produced daily Dividing fluids throughout the day Types of fluid Acceptable fluids (l.e. ginger ale) Fluids to avoid (l.e. dark colas) Food considered fluid (l.e. jello) Tips to reduce thirst Steps Case Study Flow Knock on door and ask permission to enter room Greet patient by name Introduce yourself Identify patient by two patient identifiers State purpose of visit Give patient protein and fluid education Mention further education at next dialysis session Give the patient a renal diabetic dietic booklet Note You must motion a knock on the virtual door I.e. Mrs. Bellum Full name and DOB will be used for virtual reality case studies The RD will provide this for this case study These can be done in any order Sodium, potassium, and phosphorus Give the patient an idea of what Blood sugars, carbohydrates, sample meals to expect next session Ask if the patient has any questions Thank the patient A-Assessment 5/06/2020 Reason for Nutrition Assessment: 62 YOF REFERRED TO RDN IN ACES DIALYSIS CLINIC FOR CONSISTENT CARBOHYDRATE/RENAL DIET EDUCATION Client History (CH): note which diagnosis is the primary or admitting diagnosis CH-2.1.1 CH-1.1.1 CH-1.1.3 CH-1.1.4 CH-1.1.6 Patient chief nutrition complaint: PT IS TIRED (PT IS ON HEMODIALYSIS) Age: 62 Sex: FEMALE Race: CAUCASIAN Language: ENGLISH Patient/Client/Family Medical/Health History: CH-2.1.1 CH-2.1.3 Patient chief nutrition complaint: PT IS TIRED (PT IS ON HEMODIALYSIS) Endocrine/metabolism: DM2 DIAGNOSED 5 YEARS AGO Social History: CH-3.1.2 CH-3.1.4 COOK CH-3.1.5 Living/housing situation (specify): LIVES WITH HUSBAND Social and medical support (specify): HUSBAND DOES THE COOKING WHEN PT IS TOO TIRED TO Geographic location of home (specify): LAS CRUCES Anthropometric Measurements (AD): AD-1.1.1.7 Stated Height: 160 CM (5'3") AD-1.1.2.16 Postdialysis weight: 64.4 KG (142#) AD-1.1.5.1 BMI: 25.2, OVERWEIGHT Nutrition Focused Physical Findings (PD): PD-1.1.5 PD-1.1.9.2 Vital signs: Digestive system: PT WITH FAIR APPETITE Anuria: PT REPORTS PRODUCING URINE "MAYBE TWO OR THREE TIMES A DAY" PD-1.1.21.5 PD-1.1.21.6 PD-1.1.21.7 Pulse rate: 85 BPM Respiratory Rate: 13 BREATHS PER MINUTE Temperature: 37 CELSIUS Food/Nutrition Related History (FH): FH-1.2.1.1 FH-1.2.2.1 FH-1.2.2.2 FH-1.2.2.3 FH-2.1.1.2 Oral fluid estimated intake in 24 hours: 900-1100 ML FLUID/DAY Estimated amount of food: 70% OF TRAY Types of food/meals: PRE-SELECT MENU Meal/snack pattern: 3-5 MEALS PER DAY AT HOME Modified diet order: CONSISTENT CARB/RENAL DIET

Understanding Health Insurance: A Guide to Billing and Reimbursement

14th Edition

ISBN:9781337679480

Author:GREEN

Publisher:GREEN

Chapter6: Icd-10-cm Coding

Section: Chapter Questions

Problem 219R

See similar textbooks