Sarah Haynes

Case Study #6

End Stage Liver Disease with GERD and Bleeding Esophageal Varices

FSHN 450 Fall 2015

Due Date: November 6, 2015

"I have not used, given or received any unauthorized assistance on this assignment."

Part 1: 1. What was the cause of the weight gain???? Patient is suffering from chronic liver failure, which means his liver is not processing correctly. Since last evaluation, pt shows acute weight gain of 4 pounds which is most likely a result of fluid retention. 2. What is the purpose of each of the patient’s medications? List any important drug:nutrient interactions. Drug Purpose Nutrient Interaction TUMS, Antacid Increases Calcium uptake, take

at different times than Calcium Zantac Antiulcer/ AntiGERD Decreases iron and B12

absorption Lisinopril Treats hypertension and

CHF Do not take with alcohol, decrease sodium and calcium intake

Lactulose Treats constipation, laxative, decrease portal systemic encephalopathy

Take with high fiber and 1500-2000ml of water to prevent constipation. Don't take with antacid (TUMS) medication, Ca, or Mg supplement.

Octreotide Antidiarrheal Decrease fat intake to help improve GI function

Vitamin K Help to coagulate blood Maintain constant intake Compazine Treats severe N&V,

antipsychotic Take Mg supplement by 2 hr, limit caffeine.

Morphine Treats moderate to severe pain, narcotic

Take with food to help GI function, may increase thirst, dehydration

albumin iv Help to replace blood protein loss

Do not mix with other protein solutions or solutions with alcohol

furosemide iv Treats fluid retention Take on empty stomach or with milk if GI distress occurs

3. Why was a surgical jejeunostomy tube placed? A surgical jejunostomy tube was placed because the patient is suffering from an upper GI bleed and esophageal varices, meaning they should not try and pass anything through the mouth or nose such as a gastronasal tube or a PEG because it could make the bleedings worse or even rupture a varices. 4. Evaluate the patient’s nutrient needs and prescribe a tube feeding including type and brand name, total volume and rate. Include a start rate and progression. Include ONLY the Assessment section of the ADIME at this point.

Nutrient Needs Calories: 30kcal/KgBW/Day = 30 x 88 =2640 * recommended 30-40 kcal for end stage liver disease and patient is obese Protein: 0.5g pro/ KgBW/Day = 44 grams *start at 0.5 for end stage liver disease (increase by .25 as tolerated) Fluid: 1500-2000 ml/day *Fluid Restricted due to decreased liver function Tube Feeding Type: Nutrihep Brand Name: Nestle Total Volume: 2640kcal/1.5kcal per ml= 1760/24 hrs= 73ml/hr over 24 hours. Start Rate: 10 ml/hr, progression = 10-20ml every four hours to 70ml/ hr Rate: 73 ml/hr over 24 hours for a total volume of 1760 ml ASSESSMENT: 57 y/o male admitted from Emergencies Services c/o N&V, and abdominal pain radiating to Rt side. Patient presents with scleral icterus, increased abdominal girth secondary to ascites and black stools and has been diagnosed with an Upper GI bleed and Cirrhosis. It is also important to note that patient is an alcoholic. Anthropometric Data: Current Weight: 194# Usual Weight: 190# Ht: 5’ 7” Current BMI: 30.4 Energy Requirements: Calories: 30kcal/KgBW/Day = 30 x 88 =2640 * recommended 30-40 kcal for end stage liver disease and patient is obese Protein: 0.5g pro/ KgBW/Day = 44 grams *start at 0.5 for end stage liver disease (increase by .25 as tolerated) Fluid: 1500-2000 ml/day *Fluid Restricted due to decreased liver function Physical: Ht. 5'7” Current BW 190 # BP 128/80 Pulse 90 RR 16 Temp 98.9 Relevant Labs: Decreased: Sodium Chloride CO2 Hgb Hct Albumin HDL cholesterol Increased: Creatine PTT Triglycerides Total Cholesterol

Medical Hx Htn, cholecystectomy, alcoholism Social Hx: Divorced for past 15 years. Mother living. Father died at age 65 from CHF. 4 living siblings: brother 53 has atherosclerotic heart disease, brother 40 and sister 46 in apparent good health, sister age 48 is obese. Diet Hx: High intake of carbohydrate including excessive alcohol intake. Does not eat any fruits or vegetables, is lacking whole grains and lean protein sources. Part 2: 1. List the probable reasons for the tube feeding intolerance in this patient? The patient was unable to tolerate the EN feeding because his GI tract is in high distress. He is exhibiting GI tract bleeding and can not absorb the nutrients through his intestinal tract. 2. You do not need to calculate a TPN but you should reevaluate protein and Kcal needs. Protein: 0.8 g per Kg of BW = 0.8 x 88 = 70.4 * Increased due to encephalopathy Kcal: 30kcal/ KgBW = 30 x 88 = 2640kcal/ day 3. Why was Hepatamine® ordered and what at is the drawback to using this product? Hepatamine was ordered for this patient because it has a combination of essential and non-essential amino acids with an increased proportion of branched-chain amino acids to aromatic ring amino acids. This ratio will help to decrease blood ammonia levels and regulate serum amino acids, which is important for patients with encephalopathy and cirrhosis. Drawbacks to using this product including raising BUN levels, increasing blood pressure and increasing fluid retention. 4.Why was a soft diet ordered? The soft diet was ordered because of the esophageal varices. If those rupture then the patient could potentially bleed to death. 5. Conduct a follow-up nutrition assessment and report in ADIME format for transition to oral diet (on 7/11) Assessment: 57 y/o male presents with chronic alcoholic cirrhosis with stable encephalopathy and esophageal varices. He is recently being prepared for discharge after a 3-week stay in the hospital during which he exhibited malnutrition symptoms and liver failure. During his stay in the hospital pt was transferred from EN nutrition to TPN nutrition and is currently transitioning back to solid foods. At the hospital he developed mild asterixis and 2+ edema and has been prescribed a clear liquid diet progressing to oral diet as tolerated. Fluid has been restricted to 2000 ml/day, 2300 mg sodium, and a soft diet. Anthropometric Data: Current Weight: 194# Usual Weight: 190# Ideal BW: 133-163lbs. *hamwai equation Ht: 5’ 7” Current BMI: 30.4

Energy Requirements: Calories: 30kcal/KgBW/Day = 30 x 88 =2640 * recommended 30-40 kcal for end stage liver disease and patient is obese Protein: 0.8g pro/ KgBW/Day = 70.4 grams Fluid: 2000 ml/day *Fluid Restricted due to decreased liver function Relevant Labs: Decreased: Sodium CO2 Hgb Hct Albumin Increased: Creatine PTT Medical Hx Surgical jejeunostomy, Htn, cholecystectomy, alcoholism. Social Hx: Divorced for past 15 years. Mother living. Father died at age 65 from CHF. 4 living siblings: brother 53 has atherosclerotic heart disease, brother 40 and sister 46 in apparent good health, sister age 48 is obese. Diet Hx: Prior to hospitalization, pt exhibited high intake of carbohydrate including excessive alcohol intake. Did not eat any fruits or vegetables, lacked whole grains and lean protein sources. Diagnosis: Intervention: Monitoring/Evaluation 1. Intake: Predicted suboptimal intake r/t chronic alcoholic cirrhosis aeb recent TPN and prescription of soft diet. Intervention: Explained to client the differences between liquid foods, soft foods and hard foods. Demonstrated to client how to make hard food softer. For example, steaming carrots until very soft. Researched different nutrient filled smoothie recipes and gave patient a hand out with several different recipes. Set smart goal with client to drink a supplemental nutrition drink 4 days of the week and make a healthy smoothie from the recipes we found the other three days of the week. He will repeat this process until the next evaluation in 3 weeks. Monitor/Evaluate: 2. Clinical: Swallowing difficulty r/t esophageal varices aeb liquid diet progressing to soft diet as tolerated. Intervention: Explained to patient the importance of monitoring what he swallowed. Helped client to understand swallowing foods with sharp edges such as chips could be very dangerous and cause ruptures of his esophageal varices which may cause intense bleeding. Coached client on how to incorporate every food group into his diet in the form of soft foods. Educated client on the consequences of malnutrition and explained importance of adding fruits and vegetables to his diet.

Set smart goal to eat at least one serving of soft food from each food group over the course of a day until our next appointment. Monitor/Evaluate: Asked client to explain what foods he was choosing from each food and how he felt his body was accepting them. Evaluate nutrient lab values to ensure client is improving. 3. Behavior: Poor nutrition quality of life r/t chronic alcoholic cirrhosis aeb diet recall upon admittance to hospital and recent diet prescription of liquid food progressing to soft foods as tolerated. Intervention: Educated client on future affects of consuming more alcohol. Helped client to realize he must avoid alcohol at all cost in order to improve his health. Explained to client the different food groups and how he can get enough calories and nutrients on a daily basis. Client also understands that he may need to supplement his diet with a nutrient dense drink such as Ensure to achieve all of his dietary needs. Set goal with patient to keep a food journal that includes the food type, the quantity and the preparation method until follow up meeting. Monitor/Evaluate: Read through client's journal to see how he is adjusting to a soft food diet. Ask patient about state of mind and any difficulties he is having adhering to his new diet.