MEDII CASE PRESENTATION

Cally Byrne
Preceptor: Lisa Plungas, MS RD

NUTRITION ASSESSMENT

Patient Information
Client/Social History
S.B.
60 YOWM
Lives w/ companion of 12 yrs
Independent with ADLs
Chief Complaint
Weakness, confusion

Admission Dx
Liver failure

Anthropometric Measures
Height: 511
Wt (11/17/15): 241.8 lbs
Target Wt: 190 lbs adj for obesity
%IBW: 127%
BMI: 33.8

Nutrition Assessment:
241.8#

Post-Paracentesis
Dry Weight:
220.9#

Past Medical History

Esophageal Varices
Grade II Varices in distal third of the esophagus w severe portal gastropathy in the
entire stomach
Heart Disease
Hepatic Encephalopathy
Type 2 Diabetes
Cirrhosis of the liver
2 Hepatitis C & ETOH
Transplant List
Ascites
Edema
Hypertension
Alcohol abuse, in remission
Last drink: 2010
Tobacco dependence in remission

Hepatic Encephalopathy
Loss of brain function that occurs when liver is unable to remove

toxins from blood

Cause
Brought on by disorders that affect the liver
Diversion of portal blood into the systemic circulation
Precise molecular mechanisms are yet to be identified
Ammonia is thought to play an important role

Symptoms
Personality changes, intellectual impairment, confusion
Prevalence
As many as 1/3 of cirrhotic patients

Treatment
Identify and treat any factors that may have caused H.E.
May warrant protein restriction
Lactulose to prevent buildup of ammonia

Biochemical Data

Medications
Albuterol
Amikacin
Budesonide
Ciprofloxacin
Furosemide
Heparin
Lactulose
Menthol
Morphine
Nicotine Patch
Rifaximin
Spironolactone

Comparative Standards
Energy Requirements
2,591 kcal/day
30 kcal/kg
Target Body Weight
Protein Requirements
78 gm/day
0.9 g/kg
Target Body Weight

Fluid Requirements
2,591 ml/day or per MD

Diet History
Diet: NPO
Pre-admission Diet: Regular
Subjective:
Appetite varies considerably
Tries to eat small, frequent healthy meals
Eats a lot of fruit
Tries to limit sodium consumption, but occasionally craves salt

Nutrition Diagnosis
Inadequate oral intake
Related to: feelings of early satiety, decreased appetite
As evidenced by: ascites, 12.2# wt loss x 6 mos despite
fluid retention

Nutrition Intervention
Food and Nutrition Delivery
Do not recommend NPO/CL LIQ > 3d.
Advance to dental mechanical, 6 small feedings, 2G Na when
medically possible.
Nutrition Prescription
Sodium restriction (<2,000 mg/day)
4-6 feedings/day
Adequate energy and protein to meet estimated needs
Fluid restriction if recommended by MD

Nutrition Education

Nutrition Education
Sodium intake <2,000 mg/day
Small, frequent meals
Relationship between ascites and appetite
Adequate PO intake
Fluid intake
Carbohydrate controlled diet

Coordination of Care
Nursing: Obtain dry weight
Recommend ordering Vit B12 and Folate labs
Provide supplement as needed

Monitoring & Evaluation

Adequate PO intake
Goal: PO intake >75% of meals; 4-6 small frequent meals per day
Sodium
Goal: 136 148 mmol/L

Weight
Goal: Wt maintenance w/o presence of fluids

Advanced to 2g Na on 11/19
HE: improved per 11/19 med note

References
MedlinePlus. Hepatic Encephalopathy. U.S. National Library of

Medicine website.
https://www.nlm.nih.gov/medlineplus/ency/article/000302.htm.
Revised November 2015. Accessed November 19, 2013.
Cleveland Clinic. Hepatic Encephalopathy. Cleveland Clinic
website.
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanag
ement/hepatology/hepatic-encephalopathy/. Published June 2014.
Accessed November 19, 2013.
Nutrition Care Manual. Cirrhosis. Academy of Nutrition and
Dietetics website. https://www.nutritioncaremanual.org/topic.cfm?
ncm_category_id=1&ncm_toc_id=18609&ncm_heading=Nutrition
%20Care&ncm_content_id=81449#Overview. Accessed
November 18, 2015.

QUESTIONS?