Major Case Study

1/29/18

Department of State Hospital-Patton

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,

hyponatremia/polydipsia since 2008, thrombocytopenia, chronic kidney disease

(CKD)/hydronephrosis since 2008, B/L pedal edema, and urinary retention.

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

glomerular filtration rate (GFR).

Hyponatremia is common amongst psychiatric patients and is the result of psychogenic

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

of psychotropic medications, and alterations in feedback to the hypothalamic-pituitary axis

caused by chronic polydipsia may cause incidence of hyponatremia.

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

behavior amongst patients on antipsychotic medications such risperidone, haloperidol, and

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

manage impulses to drink fluids.

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.

GG is on multiple medications that have pertinent nutritional implications. Currently GG

is taking amlodipine besylate, docusate sodium, clonidine, haloperidol, hydralazine, lactulose,

lorazepam, olanzapine, omeprazole, propranolol, sodium polystyrene sulfonate, tamulosin,

tramadol HCL, and zonisamide. GG could be experiencing decreased appetite as evidenced by

(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

rit (L) (L)

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

e mg/dL (Hi) (Hi) (H) (H) (H)

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)

145 (L) (L) (L)

mEq/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

Glucose 70-110 --- --- 119 --- --- --- 77 94

mg/dl (Hi)

Globulin 2-3.5 --- --- 4 (Hi) --- --- --- --- ---

g/dL

Nutrition Assessment and Nutrition Care Plan

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

gain is desirable. GG and staff reported no gastrointestinal distress and no chewing or

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

indicated but patient is being watched by 1:1.

1st Nutrition Diagnosis.

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

meaningful counseling and expected laboratory outcomes not achieved.

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

unwilling to adhere to changes recommended, Limited Adherence to Nutrition Related

Recommendations was most suitable. The doctor is also unsure if the patient has low protein

stores AEB a low albumin of 2.8 g/dL.

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

into place a day later.

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,

sodium levels, and blood pressure are desirable.

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

estimated using 25-30 ml/kg estimating 1600-1900 ml/day.

2nd Nutrition Diagnosis.

Inadequate energy intake R/T psychological causes AEB failure to gain wt., variable intake, and

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

prevention, choking prevention, kidney dysfunction, hyperkalemia, and water intoxication. A

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

sodium, and report adherence to diet.

Quick note

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

protein/kilogram, because the patient often has variable intake.

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

factors are considered.

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

probate to force him to accept dialysis treatment.

 References

Nelms, M., Sucher K. P., Lacery, K. (2015) Nutrition Therapy and Pathophysiology.

Boston, MA: Cengage Learning

 McCauley, M., Gill, M. (2014). Psychogenic Polydipsia: The Result, or Cause of,

Deteriorating Psychotic Symptoms? A case Report of the Consequences of Water Intoxication.

Case reports in psychiatry 2015. doi: 10.1135/2015/846459

Nagasawa, S., Yajima, D., Torimitsu, S., Abe, H., Iwase, H. Fatal water intoxication

during olanzapine treatment: A case report. Legal Medicine 16 (2014) 89-91.

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Anemia in

Chronic Kidney Disease. Retrieved from: https://www.niddk.nih.gov/health-information/kidney-

disease/anemia

Bhatia., Goyal, A., Saha, R., Doval, N. (2017). Psychogenic Polydipsia-management

challenges. Shanghai Archives of Psychiarty, 29 (3).

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

trial. BMC Nephrology 13:137. doi: 10.1186/1471-2369-13-13

Study 1-Mcauley mgill

Water intoxication is a rare condition characterised by overconsumption of water.
It can occur in athletes engaging in endurance sports, users of MDMA (ecstasy), and
patients receiving total parenteral nutrition.

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).