The patient is a 42 year old male admitted to the hospital with fever, night sweats, nausea, abdominal pain, and diarrhea. He has a history of alcohol abuse, drinking 1.75 pints of hard alcohol daily for the past 3-4 months. He was diagnosed with aspiration pneumonia and cirrhosis/ascites likely due to alcohol abuse. The nutrition assessment found the patient to be overweight with abnormal liver function tests. The nutrition diagnoses were unintended weight gain related to liver dysfunction and altered nutrition related lab values also due to liver disease. The intervention plan focused on fluid restriction and diet education to manage his cirrhosis.
3. Assessment
Age: 42
Sex: M
Ht: 65”
Wt: 174# (79 kg)
IBW: 136#
Hamwi Equation for men: 106 lb + 6 lb/in over 5 ft
%IBW: 128%
BMI: 29.1 (overweight)
Adj Wt: 150#
(actual wt – IBW x 0.38) + IBW
4. Assessment
Chief complaint:
Pt was admitted due to c/o fever for 3 nights
before admission, night sweats, N/V, diffuse
abdominal pain, and watery non-bloody diarrhea.
3 weeks prior to admission the pt experienced
worsening jaundice, bilateral 2+ pitting edema,
distention of the abdomen, feeling full and
bloated, and abdominal pain.
5. Assessment
PMHx:
alcohol abuse (1.75 pints of
hard alcohol daily for the
past 3-4 months; pt is
currently participating in a 9
day involuntary
commitment for alcohol
abuse)
Aspiration PNA 1 month
ago
Recommended daily
intake of 80-proof liquor is
1.5 fl oz (44 ml)
7. Assessment
Meds: Thiamin, folate and MV; IV Vancomycin
and Zosyn; Mg++ and Phos; K+, D5NS @
125mL/hr
Labs: (10/31):
Na: 138
K+: 3.3 L
Cr: 0.7
Glucose: 129
H
Ca/Adj: 9.02
Phos: 1.8 L
Mg++: 1.2 L
Alb: 1.6 L
(11/05):
Na: 138
K+: 4.1
Cr: 1.0
Glucose: 108
Ca/Adj: 9.42
Phos: 3.2
Mg++: 3.2
Alb: 1.6 L
AST: 60 H
ALT: 37
Alk Phos: 185
H
• Diet order: 2g Na, NKFA
8. Alcoholic Liver Disease
3 stages:
1. Hepatic Steatosis: fatty infiltration is caused
by several different metabolic disturbances.
At this stage, the disease is reversible.
2. Alcoholic Hepatitis: characterized by
hepatomegaly, low albumin, and increased
bilirubin.
3. Alcoholic Cirrhosis: symptoms vary, but may
include GI bleeding, hepatic
encephalopathy, portal hypertension, and
ascites.
10. Assessment
Total nutrition care priority points: 10. Pt
assesses as moderately compromised
secondary to his diarrhea, low albumin,
and diagnosis. He will be visited within
7 days.
11. Nutrition Diagnosis
1. Unintended wt gain related to
physiological causes (liver dysfunction)
as evidenced by ascites and bilateral 2
pitting edema, and wt gain of 14# in 1
week.
2. Altered nutrition related lab values
(AST, ALT, K, Phos, Mg++ and
glucose) related to liver dysfunction as
evidenced by jaundice, edema, and
ascites.
12. Intervention
1. Continue 2g Na diet order
2. Recommend 1.5 L fluid restriction and
discontinue IV fluids; notified MD
3. Nutrition education: on diet order and
fluid restriction
4. Monitor daily wts
5. (Abstaining from alcohol)
Goals: Dry wt maintenance & limit fluid
retention
13. Cirrhosis Nutrition Therapy
Education
-Pt may feel better eating 4-6
small meals instead of 3
larger ones
-Drinking nutritional
supplements may be
necessary to get sufficient
calories
-Salt and fluids need to be
limited with ascites
14. Monitoring and Evaluation
Met with pt 5 days after admission. He
reported he had a good appetite (ate
75% of his lunch) and that his N/V/D had
resolved. His new wts indicated a 3#
fluid loss over 1 day after IV fluids were
d/c. However, pt continues with ascites
and 2+ pitting edema (pt is not on
diuretics and has not been
paracentesed.) Pt reassessed at mild
nutrition risk level related to resolved GI
symptoms and hepatic disease.
15. References
Mahan K, Escott-Stum S, Raymond J. (2012). Krause’s
Food and the Nutrition Care Process.
Academy of Nutrition and Dietetics (2013). International
Dietetics & Nutrition Terminology (IDNT) Reference
Manual.
American Dietetic Association. Cirrhosis Nutrition Therapy.
https://www.nutritioncaremanual.org/vault/editor/Docs/Cirrh
osis%20Nutrition%20Therapy.pdf
Herbold, N. & Edelstein, S. (2010). Dietitian’s Pocket
Guide to Nutrition.
Nutrition Care Priority Points worksheet, LSH
http://www.nlm.nih.gov/medlineplus/ency/article/000286.ht
m
http://pubs.niaaa.nih.gov/publications/Practitioner/Clinician
sGuide2005/clinicians_guide20Resources.htm
http://insidesurgery.com/2012/03/cirrhosis-ascites/
Thiamin, folate, and MV are always given to alcoholics, as these are the most common vitamin deficiencies that occur in alcoholics as a result of reduced intake of food in general and alterations in absorption, storage, and ability to convert nutrients to their active forms. Thiamin deficiency is what causes encephalopathy.
The D5NS @ 100 mL/hr was providing the pt with 510 kcal daily. (5% dextrose normal saline solution)
Alcoholic liver disease is the most common liver disease in the US.
Even though this pt had never been to the hospital for any s/s of liver disease, he is already in the third stage.
Portal HTN: elevated BP in portal venous system caused by obstruction of blood flow through the liver
Hepatic encephalopathy is a worsening of brain function that occurs when the liver is no longer able to remove toxic substances in the blood
14# wt gain in 1 week
Energy needs in advanced liver disease with cirrhosis is high – 1.5 to 1.75 stress factor
When encephalopathy is present, protein needs are higher. But in uncomplicated cirrhosis, 0.8- 1 stress factor is recommended. I actually want to check with the doctor to about encephalopathy, as the pt did seem confused and slightly out of it during visits. Normally, the adj wt would be used to calculate protein – bc his wt of 174# put him at over 125% of his IBW. But, if we use the dry wt, he is only 117% of his IBW and this wt can be used to estimate his protein needs.
Talking to the pt about abstaining from alcohol is not as necessary in the clinical setting, bc the patient is obviously abstaining. However, in outpatient or community settings, encouraging individuals with liver disease to limit alcohol intake is important; especially encouraging them that during the first stage and possibly even the second stage of the disease, it can be reversible. Resources for education on alcohol intake can be found at http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm
Pt’s will often have a loss of appetite and taste changes. Small frequent feedings, as well as high calorie foods are good options.
We were worried about his diarrhea when we asked the doctor to stop his IV fluids – but his D ended up resolving, indicating that it may have also been related to the Ivs.
