University of Minnesota



Your Name and/or Name of Partner (if working with one):

Kelly Machmeier

Emma Hadler

University of Minnesota - Department of Food Science & Nutrition

FScN 4665 - Medical Nutrition Therapy I - Fall 2013

Case 3 - Revised

100 Points

Due Date: Tuesday, November 19 (new due date)

Please be sure to do the following:

• Show all calculations, and explain your rationale. Calculations do not have to be typed.

• Answer all questions directly on this form. Type all answers (except calculations). Submit in hard copy in class on the due date. You will be deducted one point per day after the due date until the hard copy is turned in.

• You may work ALONE or with ONE other person. Do not share your work with other individuals beyond your group. If you work with a partner, you should hand in only ONE case with your name and your partner’s name clearly listed at the top of the first page.

Some resources needed for solving the Case:

1. Lecture notes and materials posted under the class topic “Hepatic Disorders” in Moodle site

2. Lecture notes on Nutrition Assessment I-History and Physical Examination

3. Lecture notes on Nutrition Assessment II- Anthropometry

4. Lecture notes on Nutrition Assessment III-Biochemical/Laboratory

5. Module I: Nutrition Care Process, Nutrition Diagnosis and Medical Record Documentation

6. Module II: Energy, Protein, and Fluid Requirements in the Clinical Setting

7. Module III: An Introduction to the Exchange Lists for Meal Planning

8. IDNT Manual

9. Krause’s Food and the Nutrition Care Process, 13th edition

Alcoholic Cirrhosis

(Excerpted from Billon, W. Case 33 Alcoholic Cirrhosis, in Clinical Nutrition Case Studies, 3rd edition, West/Wadsworth, Belmont, CA. 1999; pp. 271 – 278.)

ABBREVIATIONS:

Knowledge of the following abbreviations is required in order to understand this case.

ALT: Alanine aminotransferase

AST: Aspartate aminotransferase

BRB: Bright red blood

DTs: Delirium tremens

D5W: 5% dextrose in water

Dx: Diagnosis

GGT: Gammaglutamyl transferase (or transpeptidase)

I.V.: Intravenous

N/G: Nasogastric

NH3: Ammonia

NPO: Nothing by mouth (nil per os)

Patient Hx:

Mr. N is a 45-year-old automobile mechanic. He is divorced with two children who are in college. He has long suffered from depression, and has a long-standing history of alcohol abuse. About a year ago, he had been admitted to the hospital for treatment of acute pancreatitis and an enlarged fatty liver. He had been told to follow a low-fat, high protein diet with absolutely no alcohol. He improved for a while, but then went back to drinking.

Approximately 6 months ago, he was admitted to the hospital with a diagnosis of Laennec’s cirrhosis with pancreatitis. At that time, he was again discharged with the direction to follow a low-fat, high protein, low sodium diet, and to completely abstain from alcohol. Over the past couple of months he has experienced a gradual decline. Mr. N’s condition has worsened significantly over the past week. He is admitted to the hospital with ascites and pedal edema. His urinary output has been decreasing, and he has not been following his diet at all.

Physical Examination/Anthropometric Data:

General appearance: Tired-looking male

Height: 5’ 11”

Admission Weight: 150 lbs

Weight today: 155 lbs

Weight 2 weeks ago (prior to the development of ascites and peripheral edema): 140 lbs

Weight 6 months ago (Usual Body Weight): 170 lbs

Ascites and 1+ pedal edema

Exhibits loss of muscle mass (temporal, interosseous) and subcutaneous fat (triceps, orbital)

Measured REE (today): 1720 kcals/d

Nutrition Hx:

General: Poor appetite for the past few weeks. He has been eating very little, and has not been receiving the nutrients he needs. He has continued to lose weight. He drinks little water, and reports consuming about 20 fl oz of vodka every day.

24-hour recall:

Breakfast: 16 oz coffee (black), 1 Tbsp half and half, 1 tsp sugar, 2 slices white bread, 2 Tbsp butter (stick)

Lunch: Spaghetti with meat sauce: 1 c cooked spaghetti noodles, ½ c spaghetti sauce, 1 oz cooked ground beef, 12 fl oz Vodka

Dinner: Chicken sandwich, 8 fl oz Vodka

Hospital course:

After a few days without alcohol, Mr. N began to have DTs and had to be restrained. During this time, he began to hallucinate and use very abusive language. He also started to exhibit asterixis. Blood NH3 was drawn and was 40 units/L. His food and fluid intake dropped to almost nothing. He was receiving D5W by I.V. with added vitamins, minerals, and electrolytes. That night he started throwing up large amounts of BRB. A Sengstaken-Blakemore tube had to be placed. Mr. N bled so excessively that whole blood had to be administered. His physician added to his Dx the following:

1. Hepatic encephalopathy

2. Portal hypertension

3. Esophageal varices

Mr. N was now in a semi-comatose state and had to keep the Sengstaken-Blakemore tube in place for another day. After the tube was removed, Mr. N had a N/G tube in place to low intermittent suction. He was NPO and continued to receive D5W by I.V. with electrolytes, vitamins, and minerals. Mr. N continued to have severe ascites and 2+ pedal edema, with reduced urinary output. He had some blood drawn again, and his blood NH3 was now up to 92 units/L. His prothrombin time was increased above the normal range by 4 seconds. His serum albumin was down to 2.0 g/dL. AST was 2x the ALT level, and GGT was 800 IU/L. New orders for Mr. N included the following:

1. Spironolactone (Aldactone) I.V.

2. Furosemide (Lasix) I.V.

3. Lactulose enema

4. Neomycin via N/G tube

5. D5W at 75 cc/hr

The physician requested a nutrition consult for recommendations regarding an appropriate tube feeding and flow rate.

UNDERSTANDING THE PATHOPHYSIOLOGY

1. Define the following terms:

A Sengstaken-Blakemore tube is a medical device consisting of a plastic tube and balloons. The tube is inserted into the nose or mouth and helps control upper gastrointestinal bleeding such as esophageal varices. The balloon on the end of the tube is inflated inside of the stomach, to help reduce the blood blow to the varices and stop the bleeding.

a. Sengstaken-Blakemore tube (2 points)

Hepatic encephalopathy is most commonly the result of liver failure/cirrhosis.  It is characterized by neuropsychiatric abnormalities such as altered state of consciousness, intellectual impairment, and personality changes.  The patient can also exhibit asterixis (see below) or fetor hepatics.  There are four stages of hepatic encephalopathy; the first stage consists of mild confusion and agitation, and with progression to stage 4, the patient will often be in a coma.

b. Hepatic encephalopathy (AKA portal systemic encephalopathy) (2 points)

Asterixis, also defined as a flapping tremor, is a motor disorder characterized by jerking movements of the hand when it is extended and bent upward at the wrist.  It is caused by abnormal function of the motor centers in the brain, often a result of hepatic encephalopathy.  

c. Asterixis (2 points)

Portal hypertension often causes esophageal varice. At a high portal pressure gradient, blood flow in the liver portal system is redirected into areas with lower venous pressure.  Circulation then develops in places such as the esophagus, and the blood vessels in these areas become thinner, veins dilate, and varices will occur, which is the cause of bleeding. Additionally, protein in the blood gets digested, so ammonia is produced which can further affect the liver.

2. Explain the pathophysiology of esophageal varices and portal hypertension as it relates to liver disease and Mr. N’s bleeding. (4 points)

Prothrombin time, or clotting time, is prolonged  in patients with liver disease.  It is often measured to diagnose and understand the severity of liver disease. Since most clotting factors are made in the liver, if there is liver disease these clotting factors will be sacrificed and therefor it will be more difficult for platelets to stop or slow bleeding (clotting).  This can lead to a risk of hemorrhaging.   Additionally, vitamin K is stored in the liver so a defect in the liver/liver tissue will sacrifice vitamin K utilization, which is a component of clotting factors as well.

3. What is the relationship between prothrombin time and liver disease? (4 points)

4. Mr. N’s AST was 2X ALT and GGT was 800 IU/L. What do each of these findings tell the physician about Mr. N’s liver? (4 points)

AST and ALT levels are often compared and used as diagnostic tools for diseases and conditions (Krause 1096). AST and ALT are both enzymes found primarily in the liver. And AST value 2X the ALT value indicates alcoholic cirrhosis of the liver. Additionally, GGT, a biliary excretory enzyme, is often used to evaluate the progression of liver disease and screening for alcoholism. The reference range for GGT is 12-38UL for males (Krause 1096). An increased GGT value indicates liver disease, thus Mr. N’s lab GGT value of 800IU/L is also an indicator for liver disease.

Mr. N’s elevated ammonia levels prior to bleeding, refer to the incapacities and already present failure of his liver. Prior to bleeding, Mr. N’s liver was already affected do to his alcoholic intake and malnutrition (ie protein); thus oxidative stress was occurring in liver cells and tissue, causing damage. With liver damage, the liver cannot detoxify ammonia to urea, so ammonia builds up in the blood as well as the brain, which is the cause of impaired neural function.

Mr. N’s ammonia levels are still elevated after bleeding, due to the metabolism of endogenous protein, causing degradation of blood from the GI bleeding. The protein in the blood is being digested, leading to elevated levels of ammonia.

Thus, it is somewhat of a “viscous cycle” as ammonia accumulation can lead to liver failure and liver failure will further lead to ammonia accumulation.

5. What is the significance of Mr. N’s ammonia level being elevated prior to his bleeding? What is the significance of it being elevated to an even greater degree AFTER his bleeding? (4 points)

NUTRITION ASSESSMENT

Dietary Intake Data

6. From Mr. N’s typical dietary intake, calculate the total number of calories he consumed. Also calculate the energy distribution of calories for protein, carbohydrate, and fat. For this question, you must use the Exchange Lists for Meal Planning (Use Appendix 34 in the back of the Krause text: See pp. 1110-1121 (13th ed.) and Module III, “An Introduction to the Exchange Lists for Meal Planning”), and complete each of the steps outlined below, showing your calculations.

Step 1: Determine what each food counts as, in terms of exchanges. Please count carbohydrate that is designated as such under “Other Carbohydrate” or “Combination” lists as simply “Carbohydrate” rather than “Starch”, and then count these separately under “Other Carbohydrates” in the table for Step 2. Complete the table below. (6 points)

|Breakfast | |

| |Counts As (Specify Exchanges) |

|16 oz coffee (black) |Free |

|1 Tbsp half and half |½ Fat |

|1 tsp sugar |1/3 Other Carbohydrate |

|2 slices bread, white |2 Starch |

|2 Tbsp butter (stick) |6 Fat |

| | |

|Lunch | |

|Spaghetti with meat sauce: | |

| 1 c cooked spaghetti noodles |3 Starch |

| ½ c spaghetti sauce |1 Starch |

| 1 oz cooked ground beef |1 Medium-Fat Meat |

|12 fl oz Vodka |8 Alcohol Equivalents |

| | |

|Dinner | |

|Chicken sandwich, grilled |3 Carbohydrate, 4 Lean Meat |

|8 fl oz Vodka |5 1/3 Alcohol Equivalents |

Step 2: Add the totals from the table in step 1. Count all items that were listed anywhere besides the “STARCH” list, that counted as carbohydrate exchanges, under the “Other carbohydrate” section in the table below. Count as starches ONLY those foods listed specifically on the STARCH list. (10 points)

|Exchange Group |Total |CHO |Protein |Fat |

| |servings/ |(g) |(g) |(g) |

| |day | | | |

|Starch |6 |15 |3 |Use 0 |

| | |90 |18 |0 |

|Non-Starchy Vegetables |      |5 |2 |0 |

| | |      |      |      |

|Fruit |      |15 |0 |0 |

| | |      |      |      |

|Other Carbohydrates |3 1/3 |15 |0 |0 |

| | |50 |0 |0 |

|Fat-Free Milk (1/2 %) |      |12 |8 |0 |

| | |      |      |      |

|Low-Fat Milk (1%) |      |12 |8 |3 |

| | |      |      |      |

|Reduced-Fat Milk (2%) |      |12 |8 |5 |

| | |      |      |      |

|Whole Milk |      |12 |8 |8 |

| | |      |      |      |

|Very Lean Meats/Substitutes |      |0 |7 |Use 0 |

| | |      |      |      |

|Lean Meats/Substitutes |4 |0 |7 |3 |

| | |0 |28 |12 |

|Medium Fat Meats/Substitutes |1 |0 |7 |5 |

| | |0 |1 |5 |

|High Fat Meats/Substitutes |      |0 |7 |8 |

| | |      |      |      |

|Fats | 6.5 |0 |0 |5 |

| | |0 |0 |32.5 |

|TOTAL grams |140 |47 |49.5 |

|Determine kcals by multiplying TOTAL grams |X 4= |X 4 = |X 9 = |

| |560 |188 |446 |

|Alcohol equivalent |13.33 |

|Alcohol Calories (1 alcohol equivalent = 100 calories) |1333 |

|GRAND TOTAL KCALS (CHO + protein + fat + alcohol) |2527 |

Step 3: Determine the % kcals provided by CHO. (1 point)

560/2527 = 22% of total kcals provided by CHO

188/2527 = 7% of total kcals provided by protein

Step 4: Determine the % kcals provided by protein. (1 point)

446/2527 = 18% of total kcals provided by fat

Step 5: Determine the % kcals provided by fat. (1 point)

1333/2527 = 53% of kcals provided by alcohol

Step 6: Determine the % kcals provided by alcohol. (1 point)

Anthropometric Data

7.

We decided that his weight two weeks ago, 140 lbs, would be the most accurate weight to use for the assessment. This is because during this time, he did not have ascites and peripheral edema which would account for additional body weight.

a. Which body weight will you use as the most “accurate” weight to reflect his “actual” or “dry” body weight for your assessment? EXPLAIN your thinking. (3 points)

b. Evaluate the weight you chose in part 7 a. in terms of % ideal body weight using the Hamwi equation. (3 points)

106lbs + 6(11) = 172lbs ( Ideal body weight using Hamwi equation

140/172 = 81%. Mr.N is 81% of his ideal body weight. His UBW is 170, very close to his ideal body weight. However, neither of these values is a good indication of his nutritional status, as much of his body weight is from the caloric intake of alcohol, and “unhealthy” fatty tissues.

c. Evaluate the weight you chose in part 7 a in terms of change from usual body weight over time (be specific). If he has lost weight, is it clinically significant? Explain. (3 points)

UBW = 170 lbs

% Weight Loss = ((170-140)/170) x 100 = 18% weight loss over the past 6 months. Under these circumstances, Mr. N’s weight loss would be classified as clinically severe because he has lost over 10% of his usual body weight in 6 months (technically 6 months – 2 weeks ago). His current weight gain is the result of his edema and ascites. Either way, his fluctuation in weight, due to several factors such as his nutritional history of “continuing to lose weight and not getting enough nutrients and water”, is of great concern.

8. Evaluate Mr. N’s dietary intake, anthropometric, PE/clinical, and biochemical data pertinent to his medical status. When appropriate, compare his data to standard/normal values. Be as thorough and SPECIFIC as possible, and then clearly identify at least ONE piece of data that is of concern from a nutritional standpoint within each data category as you begin to prioritize the most prominent nutrition issues that need to be addressed. EXPLAIN your rationale for each issue that you mention.

Mr. N has several concerns from a dietary standpoint, but we believe the most significant is his fluid intake. According to Krause pg. 82, “Clinical Insight to Water Requirements”, men should consume approximately 11.5 cups of fluid daily. Mr. N is currently only consuming 4.5 cups, none of which are water or healthy beverages. 2.5 of these cups are strictly in the form of vodka and the rest are from coffee. This is of great nutritional concern. Not only should he be consuming significantly less alcohol, but he should be consuming at 6-10 cups of water each day, combined with other healthy beverage alternatives (i.e. milk, all-natural fruit juice, etc.).

a. Dietary intake data (Refer back to what you found in question #6 and evaluate Mr. N’s intake in terms of major nutrients or food groups that appear to be lacking, any obvious problems you think he is having with intake) (2 points):

As mentioned above, Mr. N’s fluctuation in weight over the past 6 months is concerning. 2 weeks ago, he was at only 81% of his ideal body weight (172 lbs). He is currently at about 90% of his ideal body weight which for a healthy individual would not be of too much concern; however this of concern for Mr. N because much of his weight gain is due to the fluid accumulation (edema) and ascites due to his liver failure and decreased urinary output.

b. Anthropometric data (refer back to your answers in question #7) (2 points):

During his physical examination, it was noted that Mr. N’s general appearance was “tired-looking”. This could be due to a variety of factors, but we think that it is most likely due to his poor dietary intake, of both foods and beverages. He is not drinking enough water (see above), as more than half of his kcals come from alcohol, as without water the body cannot maintain its normal function causing fatigue. Also, a lack of protein in the diet as well as B Vitamins can also cause fatigue as these nutrients provide energy to the body. Another way to put it is if the body does not have these nutrients, it has to work harder to compensate, making the patient more tired.

Additionally, according to the NIH, “fatigue arises from changes in neuro-transmitter systems within the brain”, which can be explained by his liver diseases. Each of these factors likely feeds off one another causing Mr. N to be exhausted and fatigued.

c. PE/clinical findings (2 points):

d. Biochemical data (2 points):

e.

Mr. N’s serum albumin levels can be evaluated to help indicate his nutritional status. His current lab value is 2.0 g/dL. The reference range for serum albumin is 3.5-5 g/dL (Krause 1082). A decreased level of albumin can often indicate short-term protein and/or energy deficiency, and is often associated with other deficiencies such as zinc, iron, and Vitamin A. Many of these vitamins and nutrients are found in lean meats and vegetables, many of which are lacking from Mr. N’s diet. His very high alcohol intake may also be sacrificing the utilization/uptake of these nutrients.

9. Explain the mechanism of action of the following drugs, in terms of how it works to treat portal systemic encephalopathy. Determine any food-medication interactions and nutrition recommendations for consumption. (6 points)

|Medication |Rationale for Use/Action |Food-Medication Interactions |Nutrition Recommendations |

| |Aldactone is a potassium-sparing diuretic. It|Salt substitutes, potassium supplements |The patient should avoid salt substitutes |

|Spironolactone |increases renal resorption of potassium by |(can affect the Na/K balance). Taking |and foods high in sodium, as well as |

|(Aldactone) |acting as an antagonist of aldosterone. This |this drug with alcohol may also induced |potassium supplements or consuming a large|

| |is carried out by acting primarily through |lowered blood pressure. |excess of potassium in the diet. Alcohol |

| |competitive binding of receptors at the | |should be consumed in moderation if taking|

| |aldosterone-dependent sodium-potassium |Spironolactone can lower blood sodium |this drug. |

| |exchange site, in the distal convoluted renal|levels while raising blood potassium | |

| |tubule. |levels. Excessively high blood potassium | |

| | |levels can lead to potentially | |

| | |life-threatening abnormalities in the | |

| | |rhythm of the heart. | |

| |Furosemide is a loop diuretic used to reduce |Licorice |Patient should maintain a diet high in |

|Furosemide (Lasix) |extra fluid in the body (edema). It works by | |potassium, magnesium, and calcium. They |

| |inhibiting NKCC2, the luminal Na-K-2Cl |Some interactions with ethacrynic acid, |should avoid licorice which could |

| |symporter |cisapride, aspirin (drugs). |counteract with the diuretics of the drug.|

| | | |Electrolytes should be monitored, and |

| | | |supplementation may be necessary. |

| |Lactulose is a synthetic, non-digestible |Laxative medications should not be used |In high dosages or in sensitive |

|Lactulose |disaccharide used to treat hepatic |with this drug. Sodium and fluid intake |individuals, excess lactulose dosage can |

| |encephalopathy. |should be monitored. It should also not |result in dehydration and electrolytic |

| | |be used in patients with a diet low in |disturbances such as high sodium levels. |

| |It is metabolized in the colon by bacterial |galactose. Additionally, the use of |Thus fluids such as water should be |

| |flora to short chain fatty acids including |antacids may make it harder to absorb |consumed as well as reducing sodium in the|

| |the production of the lactic acid and acetic |lactulose. |diet. It may cause bloating, nausea, or |

| |acid. This partially dissociates, acidifying | |stomach pain, so pre and probiotics may |

| |the colonic contents (increasing the H+ | |also be recommended. |

| |concentration in the gut). This favors the | | |

| |formation of the nonabsorbable NH4+ from NH3,| | |

| |trapping NH3 in the colon and effectively | | |

| |reducing plasma NH3 concentrations. | | |

| |Neomycin is an antibiotic that kills bacteria|No known interactions, but it may |May cause diarrhea so probiotics may be |

|Neomycin |in the gut that produces ammonia. By killing|decrease the absorption or increase the |helpful. Fluid intake should also be |

| |bacteria in the intestinal tract, it keeps |elimination of many nutrients. If being |increased. It may also compromise vitamin |

| |ammonia levels low and helps to counteract |used to treat hepatic coma (likely in |and mineral absorption so supplementation |

| |hepatic encephalopathy. It can also help |this case), foods high in protein should |of Vit. B6 or K may be recommended. |

| |reduce the symptoms of hepatic coma. |be avoided. (However, this patient is |Medication management of neomycin with |

| | |lacking protein and its benefits may |furosemide should be monitored (damage to |

| | |outweigh this particular drug |kidneys or hearing loss could occur). |

| | |interaction). | |

Calculation of Nutrient Needs

10. Refer to the guidelines given in “Module II: Energy, Protein, and Fluid Requirements in the Clinical Setting” and the EAL to complete the following. Show your work and specify the source for your answers, and explain your reasoning for making the choices you made.

According to ESPEN Guidelines for Nutrition in Liver Disease and Transplantation, “when indirect calorimetry is not available, energy expenditure may be calculated from the Harris Benedict equation.”

RMR = 66.47 + 13.75 (64kg) + 5 (180cm) – 6.76 (45 yrs) = 1542 kcals

To estimate TEE, we chose to use a stress factor of 1.4 because he is likely experiencing severe metabolic stress.

1542 X 1.4 = 2159 kcals



A. Using an appropriate prediction equation (with or without activity/stress or injury factor, as you deem appropriate), estimate Mr. N’s total energy requirement. As always, explain your thinking and show your work. (4 points)

The recommended energy intake for patients with Alcoholic Cirrhosis/Laennec’s Cirrhosis, as suggested in the Hepatic Disorders class notes, is 30-35 kcal/kg, using indirect calorimetry. Using these guidelines and a body weight of 64 kg (140lbs/2.2kg/lb; using 140 lbs as his reference weight).

Mr. N’s total energy requirement would be about 64kg X 33kcal/kg = 2110 kcals/day.

What we think is most important is nutrition counseling with the patient; ie this value should be experimented with alongside nutrition education and counseling. If his condition progresses this kcal/kg recommendation may change due to decreased liver function or decreased mobility.

Cross-check your answer found in 10A by calculating what your assessed total energy requirement is on a kcal/kg basis. You do this by taking the total energy requirement estimated by your prediction equation method and dividing it by Mr. N’s weight to get kcal/kg. How does the number you calculate compare to the consensus numbers provided in Module II (i.e. is it within the range of what RDs tend to use, even though this practice is not evidence-based per se)? Show your calculations. (2 points)

According to the Hepatic class note and class lecture, protein intake for hepatic patients is about 1.2-1.5 g/kg. Thus, Mr.N’s estimated protein requirement would be 76-96 grams.

B. Estimate Mr. N’s protein requirement. Explain your thinking and show your work. (2 points)

Using the Holliday-Segar method, Mr. N would require about 2,380 mL of fluid.

1500 + 20(64kg-20kg) = 2,380 mL.

Alternatively, you could use the “Method 2” Guidelines as indicated in Module 2, which suggest 35mL/kg.

35mL(64kg) = 2,240 mL.

Both of these values are fairly close; Mr. N needs to greatly increase his fluid intake, and replace his alcohol intake with water.

C. Using guidelines given in Module II, estimate Mr. N’s fluid needs. Show your work. (2 points)

NUTRITION DIAGNOSIS

According to the Jensen article “Adult Nutrition Assessment Tutorial”, Mr. N would be classified as having “Clinical malnutrition syndrome: chronic disease-associated malnutrition.” The ASPEN article also confirms that he would have “chronic disease-associated malnutrition.”

The supporting evidence is as follows:

- Cirrhosis is consistent with malnutrition and chronic inflammation of mild to moderate degree.

- Anthropometric data: Ascites and weight gain mask true underweight status and loss of body cell mass. Other body composition measures may demonstrate loss of muscle.

- Dietary intake: Severely compromised for weeks.

- Loss of muscle and subcutaneous fat exhibited during physical exam

11. Based on your assessment in question # 8 , refer to the Jensen article (Jensen GL, Hsiao PY, Wheeler D. Adult Nutrition Assessment Tutorial. J Parenter Enteral Nutr 2012;36(3): 267-274.) and the ASPEN/Academy Consensus Statement (White JV, Guenter P, Jensen GL, Malone A, Schofield M. Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). J Parenter Enteral Nutr 2012;36(3):275-283.) to determine if Mr. N meets the definition of a specific category of malnutrition. Explain your rationale. (2 points)

12. Refer to Module I: the Nutrition Care Process, Nutrition Diagnosis and Medical Record Documentation and your IDNT Reference Manual. Based on what you discovered in earlier questions, identify TWO of Mr N’s most prominent nutrition-related problems within any of the domains (INTAKE, CLINICAL and/or BEHAVIORAL- ENVIRONMENTAL DOMAINS) using the standard Nutrition Diagnostic Terminology and INCLUDE the CODE # from the IDNT manual for each nutrition diagnosis you write. Even if you determined in the preceding question that he is malnourished, choose two nutritional diagnoses OTHER than malnutrition that you can address as the RD. In other words, think about the reasons why he is malnourished as you identify his most important nutrition diagnoses.

A. Nutrition Diagnosis #1: (1 point)

Excessive Alcohol Intake (NI-4.3, 10654)

Impaired Nutrient Utilization (NC 2.1, 10759)

B. Nutrition Diagnosis #2: (1 point)

13. Now go back to your two nutrition diagnoses. For each one, write a complete nutrition diagnostic statement in PES format (problem, etiology, signs and symptoms), labeling each section (P, E, and S) appropriately. Identify your short- and long-term goals, an appropriate intervention strategy to address the problem, and measurable outcomes you will monitor to evaluate the effectiveness of your intervention. You may want to use Module II, your IDNT manual, and the “What is ADIME” document on the course web site under “Reference Materials and Resources for Clinical Cases” to help you with this question.

Excessive alcohol intake (P) related to alcohol addiction (E) as evidenced by an intake of more than 2 alcoholic beverages each day, and increased AST and GGT lab values (S).

A. PES #1: (3 points)

Impaired Nutrient Utilization (P) related to hepatic encephalopathy/liver diseases (E) as evidenced by excessive alcohol intake and loss of subcutaneous fat and muscle mass (S).

B. PES #2: (3 points)

NUTRITION INTERVENTION, MONITORING, AND EVALUATION

Enteral Feeding

In the next several questions, you will be asked to develop an enteral feeding regimen for Mr. N. Regardless of how you assessed his energy and protein needs, and regardless of other factors you might have considered with regard to initiating nutrition support in Mr. N, please use the following numbers to do your calculations:

Energy requirements: 2000 kcal

Protein requirements: 75 - 95 g protein

Fluid requirements: ~1500 mL

NOTE: Use the sample calculation posted under “Enteral Nutrition Support” on the web

site to guide you through the calculations. NOTE: Think about choosing a more calorically dense formula, like Isosource 1.5, in light of the fluid restriction. You may have to make your goal TF have the higher amount of protein to get 2000 kcals, and that’s okay – think about how you would start. Or you may have sized him up as having hepatorenal syndrome- in which case, Novasource Renal might be a better choice. Provide your rationale for whatever option you choose in the space below.

14. Select an appropriate formula from the Region’s Hospital Enteral Formulary provided with the Enteral Nutrition Support notes. Explain why you chose this particular formula, citing the source for your decision. (2 points)

Isosource 1.5 is used for patient with high calorie and protein needs. Mr. N needs to replace many foods in his diet with more nutrient rich foods, including protein.

, and Enteral Nutrition Support class notes

Isosource 1.5 has 1.5 kcal/mL

Energy requirement is 2000kcal, so 2000/1.5 kcal/mL = 1,333 mL Isosource 1.5 needed to meet 2,000 kcal energy requirement

15. Determine the volume of formula needed to meet the estimated 2000 kcal energy requirement. (2 points)

1,333 mL / 24 = 56mL per hour should be administered

16. Determine the final step (goal hourly rate) in the feeding progression (for a 24-hour continuous feeding). Round the rate to the nearest whole number using the rule if < .5, round down, and if .5 or above, round up (e.g. if you calculate that you need an hourly rate of 102.3 ml per hour round down to 102, if you calculate 102.5, round up to 103. (2 points)

17. Calculate how much energy and protein your final (goal) rate will provide. Ask yourself if this volume of formula will meet assessed daily requirements for energy and protein (i.e. 2000 kcal and between 55 – 60 g protein)? (2 points)

56mL X 24 hr X 1.5 kcal/mL = 2016 kcal

56mL X 24 hr X .068 g protein/mL = 91 g protein

Yes, this formula appears as a good starting TF regimen, as it meets the 2000 kcal (is very close), and meets the protein requirement of 75-95 grams as well.

CHO = 56mL X 24 X .170 = 228g CHO

Fat = 56mL X 24 X .065 = 87g Fat

Isosource 1.5 contains 78% water

56 mL X 24 hr X .78 = 1048 mL free water

His fluid requirements are 1500 mL, so using 1500-1048, about 452 mL of additional water is required to meet Mr. N’s fluid needs.

If given 6x throughout the day (q 4 hrs), 452/6 = 75mL each flush (q 4 hours)

18. Calculate the amount of additional water required to meet fluid needs (i.e. water flush), assuming that Mr N’s hydration status is normal, and that he is no longer on any IV hydration. (2 points)

19. Complete the following enteral order form, indicating the goal TF order, as per your calculations above. (5 points)

The GOAL TF is: 1,333 mL (total 24-hour volume) of Isosource 1.5 (formula name) at the rate of 56 mL per hour for 24 hours to provide a total of 228g CHO, 91 g protein, 87g fat, 2016 kcals, 1048mL free fluid, with 75 mL of additional water flush provided 6 times per day.

20. BONUS 5 points: Describe any concerns you have about initiating your TF regimen in this patient, in light of his current nutritional status. Be specific about what you will evaluate before you initiate the feeding, and how you will progress the feeding so that you can minimize risk to the patient. State what you will monitor as you progress the feeding, so that you can ensure that the patient is safely tolerating the feeding and that you are avoiding adverse consequences as you advance the feeding to the goal hourly rate you have stated in question #19.

Feeding progression for continuous feedings with >500mOsm/kg

Day 1: Begin at 25 ml q h X 8 h; advance by 25 ml increments X 8 hours until final

step is reached, i.e. advance to 50 ml q h X 8 h, then advance to 75 ml q 8 h (or to

final volume/hour computed for the final step).

For first 8 hrs. = 25 mL q h = 200mL = 300kcal

Next 8 hrs = 50 mL q h = 400mL = 600kcal

Next 8 hrs (last) = 75 mL q h = 600mL = 900kcal

1200 mL with 1800 kcals will be provided by the end of day one.

Day 2: In most cases, with a hypertonic formula, the caloric density of the formula is

such that the goal volume will have already been reached by the end of Day 1. If the

final step has not yet been reached, then start Day 2 by advancing to 100 ml q h X 24

h (or to final volume/hour computed for the final step).:

100 mL q h for 8 hrs = 800mL = 1,200 kcal over the course of 8 hrs; this seems to be too high and too fast, thus inducing the risk for Refeeding Syndrome. Because of this risk, we will monitor Mr. N’s potassium, magnesium, and phosphorous levels to make sure that they don’t drop below normal ranges. We think that after the 75 mL q h completion, the TF regimen should be reduced to the targeted mL/hr (56mL goal hourly rate).

If this particular TF regimen is not successful, we may look to try NutriHep, often used for patients with hepatic failure/hepatic encephalopathy. Protein status should be monitored closely, and the addition of Promod may be considered.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download