Professional Documents
Culture Documents
1/29/18
Jonathan Tellier
Introduction.
GG was admitted to Department of State Hospitals-Patton (DSH-P) on 8/2/1996 at the
age of 36 with schizoaffective disorder bipolar type, which was first diagnosed at age 17. Prior to
admission he was living at a group home, where he fell under the influence of drugs stole a car
and crashed it. The only personal relationship noted in his chart is that his mother still calls
frequently to check up on him. GG has history of hypertension (HTN) since 1998, hepatitis C
virus (HCV), anemia since 2008, edentulous, chronic mild hyperkalemia since 2008,
Disease Overview.
Chronic kidney disease (CKD) is common in the United States affecting nearly one in every 10
adults and millions more are at risk of developing CKD. CKD is most commonly caused by
diabetes, HTN, and glomerulonephritis. Other risk factors include ethnicity, family history,
hereditary factors, direct forceful blow to the kidneys, and prolonged consumption of over the
counter painkillers (Nelms et al. 2015). Signs and symptoms of CKD include edema, metabolic
acidosis, anemia, uremia, hyperphosphatemia, oliguria, bone and mineral disorders, HTN, and
hyperkalemia. Blood pressure is largely regulated by sodium and chloride, as kidney function
declines sodium retention and edema occur. GG has a current diagnosis of CKD stage 4
(9/21/18) per nephrology at DSH-P. GG is retaining fluids and has a long history of water
intoxication which is most likely leading to his extreme blood pressures which average 169/93
mmHg (1/1/19-1/4/19). His history of HTN since 1998 is likely what caused his declining kidney
function. GG has history of hyperkalemia but when seen on 12/4/18 this was not an issue likely
due to the excess amount of fluid he is retaining. Hyperkalemia is the result of the kidneys not
adequately excreting potassium. When the kidneys are functioning normally they excrete 80%-
90% of the total intake of potassium each day. When followed up on 1/4/18 GG had
hyperkalemia likely a result of no longer being water intoxicated. The excess fluid dilutes his
blood causing potassium levels to be within the normal range. A few days later his potassium
levels were within normal limits likely related to medical and nutrition intervention. Microcytic
anemia is common in CKD because the kidney is no longer able to produce the hormone
erythropoietin, which stimulates the production of red blood cells. As CKD continues to progress
the ability to excrete nitrogenous waste declines and blood urea and other compounds increase,
resulting in azotemia. When function of the kidney declines renal osteodystrophy can occur. This
is from the inability of the kidney to convert inactive vitamin D to the active form calcitriol. GG
presents with many of these signs and symptoms and has continued to have fluctuating
polydipsia, which is found in about 20% of all psychiatric patients (McCauley & Gill 2014).
Hyponatremia is defined as plasma sodium levels below 135 mmol/L, symptoms however do not
occur until a drop to 115-120 mmol/L occurs. A drop-in serum sodium 120 and below only
occurs if the patient is drinking greater than 10 liters/day of water, when the maximum urine
dilution is reached which is 100 mOsm/kg, and antidiuretic hormone is fully suppressed. The
patient at this point may exhibit seizures, drowsiness, irritability, vomiting, confusion, twitching,
muscular weakness, behavioral changes, and headaches. These symptoms only occur in 20% of
patients. The etiology of psychogenic polydipsia is uncertain, however impaired water excretion
and water intoxication were noted in the early 20th century before antipsychotic medications
were used. Arginine vasopressin (AVP) is secreted by the hypothalamus and controls the solute
in the tissues. It is thought that an osmotic set point exists for AVP secretion and this set point
could be lower in-patients with polydipsia, which can lead to impairment in water excretion.
Other theories are that high dopamine levels may affect thirst, drinking to counteract side effects
One study found water intoxication has no established diagnostic criteria but is best
diagnosed by observation of behavior (Nagasawa et al. 2014). Behavior to watch for would be
constant trips to the restroom and patient constantly drinking fluid. This may be a common
olanzapine which cause dry mouth and are linked to water intoxication. Olanzapine in one study
was found to possibly aggravate water intoxication if blood concentrations were more than
optimal 20-40 ng/mL. This may be contributed to olanzapine being a multi receptor agonist,
which increases the chance of anticholinergic effects and metabolic disorders. Olanzapine used
within normal limits (WNL) can be used to treat water intoxication by reducing the patients
sense of anxiety (Bhatia et al. 2017). This treatment of water intoxication is best used when the
patient is stabilized with vasopressin receptor antagonist and given behavior therapy to help
Current Treatment.
When taking into consideration CKD, water intoxication, and his edentulous state, GG in
the past was put on a Mechanical Soft Advanced 2-gm Sodium diet with additional snacks
including mocha mix in place of milk at meals, ½ cup of applesauce and one cranberry juice at
09:00, and one pudding cup at 14:00 and 20:00, patient also does not receive salt substitute.
Although GG had a serum sodium that is low because of water intoxication, the 2-gm sodium
restriction was indicated because of blood pressure readings being as high as 207/115 mmHg on
10/20/18. This dietary restriction was discussed with the MD and implemented for one month. In
the past GG has refused dietary changes until dialysis was mentioned in an interview and GG
then became receptive to dietary changes that may slow progression of CKD.
(AEB) refusal of meals. He has fluctuating weight due to water intoxication but is currently at
the lower end of his appropriate weight range (AWR). Dry mouth could be an issue related to
antipsychotic medications AEB overconsumption of fluids. Patient was not reported to have
nausea, vomiting, constipation, diarrhea, or dyspepsia, and labs showed triglycerides and glucose
levels WNL.
Laboratory values showed declining renal function and signs of water intoxication. Low
Hemoglobin/Hematocrit (H/H) is most likely low due to decreasing kidney function. Anemia can
cause decreased function of the heart and brain because the organs are receiving less oxygen
(NIDDK). Blood urea nitrogen (BUN) and Creatinine is elevated due to decreased kidney
function as well. Although GG has fluctuating levels of these metabolites in the blood they are
relatively stable. C-reactive protein was tested to see if any inflammation was causing acute
phase protein albumin to be low. C-reactive protein came back normal, so in this case Albumin
levels would be low due to hypervolemia and not inflammatory state. Low serum sodium levels
are due to hypervolemia as well. Serum sodium has shown to fluctuate between 124-and 133
mm/dL. All serum sodium labs were not included because patient is on 1:1 for water intoxication
and gets labs done daily to monitor fluctuation in serum sodium, instead a range was taken.
Glomerular filtration rate (GFR) tends to fluctuate between CKD 3B and CKD 4, however GG
per nephrology is chronic renal failure stage 4 (9/21/18). Upon follow up on 12/4/18 the patient
showed a trend of declining serum sodium levels since implementation of 2-gm sodium
restriction.
Laborato Norma 1/16/19 1/4/19 12/27/18 12/3/18 10/30/1 10/18/18 10/10/18 9/19/18
8
ry Value l range
Hemoglo 13-17.5 --- --- 9.6 (L) --- --- --- --- 9.9 (L)
bin g/dL
Hematoc 42-52% --- --- 28.2 --- --- --- --- 28.3
BUN 10-20 67 (Hi) --- 46 (Hi) --- --- 42 (H) 35 (H) 39 (H)
mg/dL
Creatinin 0.7-1.2 3.92 --- 3.13 --- --- 2.61 2.33 2.19
Albumin 3.5-5 --- --- 2.9 (L) --- --- --- 2.8 (L) 3.1 (L)
g/dL
Sodium 136- 138 138 131 (L) 125 133 130 (L) 131 128 (L)
Potassiu 3.5-5.5 5.7 (Hi) 4.8 5.8 (Hi) --- --- --- 3.8 4.1
m mEq/d
L
GFR ≥60ml/ 16 (L) --- 21 (L) --- --- 26 (L) --- 32 (L)
None AA min/1.7
3𝑚2
mg/dl (Hi)
Globulin 2-3.5 --- --- 4 (Hi) --- --- --- --- ---
g/dL
1st Assessment. GG was found pacing in the day hall watching the news with his 1:1. When
approached GG was willing to interview, however got agitated and terminated interview when
discussion about medical conditions began. At time of visit staff reported GG to be skipping
meals, but intake has improved since last visit in October. GG does not buy any canteen per staff
although steals extra coffee at meals if not watched closely. GG displayed minimal knowledge in
regard to medical conditions however does acknowledge that he has the current conditions. GG
has told the unit registered dietitian in the past that he may change his diet as needed. Normal
behavior for GG is pacing throughout the day leading to edema in his legs and increased energy
needs. GG is 70 inches tall weighing 146 lbs. however weight is fluctuating five pounds within
one day and he has gained nine pounds within one month. His weight has remained above the
level one alarm set at 140 lbs. for the month of November and at the time of visit GG was past
his level two alarm set at 144 lbs. Current weight is below appropriate weight range and weight
swallowing problems. GG has uncontrolled blood pressure averaging 173/93 mmHg (11/25/18-
12/04/18). This uncontrolled blood pressure is likely due to his excessive fluid consumption
leading to hypervolemia.
Patient needs were estimated taking into consideration increased energy needs related to
constantly being on his feet pacing the unit and his lower than desired body weight. Needs were
estimated at 2300-2650 kcal/day (35-40 kcal/kg) the regular mechanical soft advanced diet is
adequate to meet patient needs. However, GG is getting additional snacks throughout the day to
promote weight gain, which has been working AEB his weight stable above 140 lbs. since
October. Protein needs were estimated to be 55-80 gm/day (0.8-1.2 gm/kg) and a protein
restriction was contraindicated related to possible low protein stores as evidenced by decreased
albumin. Fluid needs were estimated to be 1650-2000 ml/day (25-30 ml/kg) no fluid restriction is
Limited adherence to nutrition-related recommendations R/T lack of value for behavior change
and previous lack of success in making health-related changes AEB failure to engage in
The reason for this diagnosis is the patient was unwilling to complete the interview and has
history of refusing care although he knows that he may benefit from this care. There are other
possible diagnoses that could be used including Altered Nutrition Related Laboratory Values,
Increased Energy Needs, Excessive Fluid Intake, Excessive Protein Intake, Increased Energy
Needs, Inadequate Energy Intake, and Inadequate Oral Intake, however because the patient is
Recommendations was most suitable. The doctor is also unsure if the patient has low protein
1st Intervention.
GG is a NST IV, so he has been seen monthly by the dietitian for the past few months. His most
recent assessment the dietitian placed him on a low sodium diet in the attempt to manage his
blood pressure. After analyzing his blood sodium levels over the course of the month, this
dietitian recognized a noticeable reduction in sodium levels. To intervene the dietitian took the
patient off of the low sodium diet and restricted sodium packets at meals instead. If the patient is
receiving the normal diet without salt packets he is getting around 3000 mg of sodium each day.
To reduce the amount of potassium and phosphorus the patient has been given mocha mix in
place of milk at meals. Recommendations to limit fluid intake to preserve kidney function and
better control blood pressure were given. Education and counseling was limited due to the
patient’s minimal participation in interview. The diet change was discussed with the medical
doctor and put into the sick call book. This intervention was addressed by the physician and put
1st Goal.
The goal for next assessment is to have improved nutrition outcomes, however adherence to this
goal is fair. Patient has been unable to adhere to nutrition recommendations and other disciplines
recommendations. Previous goals were adhering to prescribed diet which was met, weight at or
above 139 lbs. which was met, patient to have stable or improved albumin which was deferred
due to no new labs done, patient to have stable or improved sodium levels which was not met,
and patient to have improved blood pressure control which was not met. The previous goals were
then made the goals for next assessment because weight gain as well as improved albumin,
2nd Assessment.
GG was found pacing the hallway outside of the day hall. He no longer has a 1:1 for water
intoxication because the physician has increased his water intoxication protocol level 1 alarm to
143 lbs. and level 2 alarm to 147 lbs. GG currently weighs 141 lbs. as of January 1st. The current
diet was updated 12/7/18 to Mechanical Soft Advanced with snacks, from Mechanical Soft
Advanced, 2gm sodium with snacks by the physician. Staff reports patient has variable intake,
picking what he likes and leaving the rest behind. Medications stayed the same over the last
month however kayexalate was given in two doses on 12/31/18 because laboratory values
showed increased potassium levels. This extra dose was able to stabilize his potassium levels at
4.8 mg/dL and possibly increased his serum sodium to 138 mg/dL. This is the first-time serum
sodium has been WNL since the unit dietitian was given this unit. GG was approached and
accepted the interview, his first question was if he can be taken off of Mechanical Soft Advanced
and be put on the regular diet. He was counseled as to why he should remain with a texture
modified diet and then accepted he should remain on the current diet.
Patient laboratory values showed worsening kidney function. The last metabolic panel
reveals that GG has elevated potassium, BUN/Creat. trending up, GFR trending down, decreased
but stable albumin, and elevated globulin. These labs are indicative of worsening kidney function
and possible inflammatory state. The physician was spoken to about possibly considering a
protein restriction but because of the possible inflammation or protein malnutrition AEB low
albumin we decided that a protein restriction was contraindicated, and that patient needs are
increased. His needs were calculated using 35-40 kcal/kg estimating the patient needs 2250-2550
kcal/day, protein needs were calculated using 0.8-1.0 g/kg estimating 50-75 g/day, and fluid was
mental illness.
This nutrition diagnosis was chosen over altered nutrition related laboratory values because our
intervention has the potential to impact the patient. If this diagnosis was chosen there is no
intervention other than putting the patient on a low potassium diet for hyperkalemia. This
however was not fully indicated because the patient was treated with an extra dose of kayexalate
on 12/31/18. This treatment lowered the potassium level from 5.8 mg/dL to 4.8 mg /dL. The
need for a low potassium diet is only indicated if hyperkalemia is present. The patient was also
not willing to change his diet voicing that he wants his diet to be changed to regular.
Intervention.
The snack chosen was graham crackers, which offers 90 kcal per serving and only 1 gram of
protein. This snack was added twice a day and will boost the total calorie count by 180 and will
not add a significant amount of protein or potassium. All other snacks were kept as is to promote
weight gain. The patient was then educated on drug nutrient interactions, constipation
handout was provided however the patient refused the handout. He was open to counseling on
foods that have a high amount of potassium including prune juice which he drinks up to three
times a day.
Nutrition Goal.
The main goal was to maintain or gain weight, however expected adherence is fair. This is
because the patient has a long history of refusing other health care and not being able to meet
goals set. The patient was able to meet previous goals including improved albumin, improved
GG had blood work done on 1/16/19. This report showed worsening kidney function with BUN,
Creat. and Potassium elevated above normal for this patient. BUN of 67 mg/dL and Creatinine
3.92 mg/dL is the most elevated these two metabolites have been, potassium was also elevated
and recorded at 5.7 mEq/dL. These labs indicate declining kidney function and both myself and
the unit dietitian thought it best to recommend a Mechanical Soft Advance, 2-3 gm potassium,
40-65 gm protein diet with snacks. These recommendations are still liberal providing 0.6-1.0 gm
Conclusion.
GG is a 58-year-old male that has been residing at DSH-P for the last 22 years. The conditions of
focus for this study include HTN, CKD, hyperkalemia, and hyponatremia/polydipsia. The
current health status of GG is most likely due to his chronic history of HTN and water
intoxication. It is hard to determine exactly what causes psychogenic polydipsia, but many
GG is currently CKD 4 and has declining kidney function. The physician voiced that he
could have declining protein stores and potential inflammation. This has led the current diet
order to only restrict dairy products to moderately decrease the amount of protein and potassium
in the diet, however weight gain is favorable considering his below ideal body weight. GG is
most likely to begin dialysis if renal function continues to decline and may need a medical
Nelms, M., Sucher K. P., Lacery, K. (2015) Nutrition Therapy and Pathophysiology.
Nagasawa, S., Yajima, D., Torimitsu, S., Abe, H., Iwase, H. Fatal water intoxication
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Anemia in
disease/anemia
McMahon, E., Bauer, J., Hawley, C., Isbel, N., Stowasser, M., Johnson, D., Hale, R.,
Campbell, K. (2012). The effect of lowering salt intake on ambulatory blood pressure to reduce
cardiovascular risk in chronic kidney disease (LowSalt CKD study): protocol of a randomized
Study 2-Nagasawa
A man in his twenties was diagnosed with schizophrenia in his late teens. The night before his
death, his family reported he drank a large amount of water, vomited, collapsed, and snored loudly while
sleeping, but they did not view the event seriously as he did it routinely.
Study 3-Bhatia
Compulsive water drinking or psychogenic polydipsia is now increasingly seen in psychiatric
populations. Effects of increased water intake can lead to hyponatremia causing symptoms of
nausea, vomiting, seizures, delirium and can even be life threatening if not recognized and
managed early. Here we present a 35-year old adult who was diagnosed with psychogenic
polydipsia and was successfully managed with a combination of pharmacotherapy, fluid
restriction and psychosocial management.
Study 4-Mchanon-
The LowSALT CKD study is a six week randomized-crossover trial assessing the effect of a
moderate (180 mmol/day) compared with a low (60 mmol/day) sodium intake on cardiovascular
risk factors and risk factors for kidney function decline in mild-moderate CKD (stage III-IV).