1. Marissa Uhlhorn
End Stage Liver Disease with GERD and Bleeding Esophageal Varices
FSHN 450
Fall 2015
Due Date: November 6, 2015
I have not given or received any unauthorized assistance on this assignment
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2. End Stage Liver Disease with GERD and Bleeding Esophageal Varices
FSHN 450
Fall 2015
Due Date: November 6, 2015
What was the cause of the weight gain?
The cause of the patient's weight gain is most likely due to edema, which is from water retention
and swelling of extremities. This is indicative of his low serum albumin levels. He was also
admitted with ascites as seen with fluid accumulation in his abdomen.
His weight gain could also be attributed to the diet he consumes. A large number of calories come
from his 7 shots of bourbon and 6 cans of beer he is consuming each day. This patient also
consumes highly processed foods, which typically are high in saturated fats and sodium.
What is the purpose of each of the patient’s medications? List any important drug/nutrient
interactions.
TUMS
o Purpose: Antacid, phosphate binder, antidiarrheal
o Diet: insure adequate fluid intake/hydration, take separately from large amounts of high
fiber, high oxalate or high phytate foods
Zantac
o Purpose: Antiulcer, anti-GERD, antisecretory
o Nutrient interaction: decreased FE & Vit B12 absorption, Mg or Al/Mg antacids
decreased drug absorption
Lisinopril
o Purpose: Antihypertensive, CHF treatment, post MI treatment
o Nutrient interaction: insure adequate fluid intake, decreased Na and cal may be
recommended. Caution with K supplements, avoid natural licorice, decreased weight
reported (anorexia)
Lactulose
o Purpose: laxative to treat increased ammonia levels
o Nutrient interactions: High fiber (with 1500-2000 ml fluid/day) to prevent constipation,
not with lactose or galactose restricted diet. Do not take concomitantly with antacids, Ca
or Mg supplements. Drug increased absorption of Ca & Mg
Octreotide
o Purpose: Antidiarrheal, also used for acute bleeding esophageal varices treatment
o Nutrient Interactions: May cause fat and fat-soluble vitamin malabsorption and delay
gastric emptying. Alters insulin, growth hormone, thyroid hormone and glucagon levels
Vitamin K
o Purpose: Treat hypoprothrobinemia and increase blood clotting
o Nutrient Interactions: Maintain consistent Vit K intake if taking anticoagulant, adequate
intake for males: 120 micrograms/day, no documented toxicity.

3. Compazine
o Purpose: Antipyschotic, antiemetic, antianxiety
o Nutrient interactions: limit caffeine, increased appetite, increased weight, and increased
need for Rib. May decrease absorption of Vit B12.
Morphine
o Purpose: Analgesic, narcotic, opioid
o Nutrient interactions: anorexia (decreased weight), increased thirst, dehydration
Albumin iv
o Purpose: Can be used to treat edema, hypovolemia, hypoalbuminemia in critically ill or
bleeding patients
Furosamide iv
o Purpose: Antihypertensive and diuretic.
o Nutrient interaction: May deplete potassium levels, can lead to anorexia and increased
thirst.
Why was a surgical jejeunostomy tube placed?
Due to the patient's history of alcoholism, his intestinal mucosa is most likely severely damaged.
This would impair digestion and absorption of nutrients, resulting in malnutrition. He would also
most likely have B1 deficiency and poor iron and folate absorption. In addition, the cirrhosis has
caused esophageal varicies causing esophageal veins to bleed easily and become swollen or weak.
Because of all of these severe factors, the patient needs a surgical jejeunostomy tube so that he
can properly absorb nutrients and avoid further malnutrition.
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.
Energy Needs: 30-35 kcal/kg BW/day
30-35 kcal * 88.2 kg= 2,646- 3,087 kcal/kg BW/day
Fat: Moderate- as tolerated: 25-35-en%
RANGE:
0.25*2,646= 661.5kcal/9g=73.5 g fat/day
0.25 * 3,087=771.8kcal/9g=85.8 g fat/day
0.35*2,646=926.1 kcal/9g=102.9 g fat/day
0.35* 3,087=1,080.5kcal/9g= 120.0 g fat/day

4. Protein Needs (clinically stable): 1.0-1.2 g/Kg BW/day
1.0-1.2g * 88.2 kg= 88.2-105.8 g/Kg BW/day
Other Vitamins/Minerals:
B12, B6, Niacin, Folic Acid for alcoholism
Iron with anemia??
Zinc and Magnesium for alcoholism
Nutrihep
1.5 kcal/ml
Total volume: 2,646-3,087kcal/1.5= 1,764 ml-2,058ml
Rate: 1,764ml-2,058ml/24 hr= 73.5ml/hr-85.8ml/hr
Start Rate: ¼ goal rate: 73.5ml/hr-85.8ml/hr *0.25=18.4 ml/hr-21.45ml/hr
Progression: Advance by 20 ml every 8-12 hrs until final volume is reached.
Assessment:
Current diagnosis: Upper GI Bleed, Cirrhosis
• Anthropometrics
◦ 57 year old male
◦ 5' 7”, 194 # (BMI: 30.4- obese)- gained 4 pounds in past 11 days
◦ BP 128/80- slightly high
◦ Pulse 90-normal
◦ RR 16- higher end of normal
◦ Temp 98.9- normal
Biochemical Indicators
◦ Na (low), Cl (low), CO2 (low), Creatinine (high), PTT (high), Hgb (low), Hct (low),
Albumin (low), TG (high), Total Cholesterol (high risk)
• Physical
◦ N&V
◦ Abdominal pain radiating to Rt side
◦ Presented with scleral icterus (possible jaundice)
◦ Increased abdominal girth
◦ Ascites- accumulation of fluid causing abdominal swelling
◦ Black stools
◦ Gained 4 pounds in 11 days (upon next visit)
• Medical History
◦ Hypertension
◦ Cholecystectomy
◦ Alcoholism
◦ Medications at home: TUMS, Zantac, Lisinopril

5. • Hospital medications: Lactulose, Octreotide, Vitamin K, Compazine, Morphine, albumin
iv, furosamide iv
• Social/Family History
◦ Divorced for 15 years.
◦ Mother living but father died at age 65 from CHF
◦ Living siblings: Brother 53 has atherosclerotic heart disease
▪ Brother 40 and sister 46 in apparent good health
▪ Sister age 48 is obese
• Diet History
◦ High calories coming from 7 shots of bourbon/day and 6 beers/day
◦ High calories, saturated fats, and sodium coming from processed foods (hot dog,
chips, condiments, pasta/macaroni and cheese
◦ Low intake (if at all) of fruits and vegetables
◦ Low protein consumption
List the probable reasons for the tube feeding intolerance in this patient?
Tube feeding intolerance is seen in this patient due to the damage of the intestinal mucosa, which
includes the jejunum. This could result in the patient’s malabsorption of key nutrients and overall
calorie consumption.
You do not need to calculate a TPN but you should reevaluate protein and Kcal needs.
This patient is most likely grade 3 of hepatic encephalopathy (due to being disoriented to
time/place, mild asterixis and edema), therefore his energy and protein needs must be adjusted.
Energy Needs: still 30-35kcal/kg BW/day
30-35 kcal * 88.2 kg= 2,646- 3,087 kcal/kg BW/day
Protein Needs: Grade 3 requires 0.5 g/kg for 2-3 day and increase by 0.25 g/kg
0.5g * 88.2 kg= 44.1 g/kg BW/day (for 2-3 days) than increase to 0.75 g * 88.2 kg= 66.15 g/kg
Why was Hepatamine® ordered and what at is the drawback to using this product?
This is given to patients with hepatic encephalopathy and cirrhosis. It also provides additional
nutrition support. A possible drawback would be that it may cause hyperglycemia which may
require insulin injections.
Why was a soft diet ordered?
A soft diet is recommended to avoid bleeding of the varicose veins. This would occur due to the
inability of the veins in the esophagus to drain, resulting in bulges that may tear or burst.
Conduct a follow-up nutrition assessment and report in ADIME format for transition to

6. oral diet (on 7/11) Develop three PES statements, one in each domain and plan an
itervention and follow-up for each nutrition diagnosis.
7/1 Laboratory
Na 122 mEq/L
K 4.1 mEq/L
Cl 98 mEq/L
CO2 10 mmol/L
Glu 93 mg/dl
BUN 18 mg/dl
Creat 1.6 mg/dl
PTT 43.1 seconds (reference: 23.7 - 32.7 seconds)
RBC 2.88 x106
/mm3
Hgb 9.1 g/dl
Hct 26.9 %
Albumin 2.6 g/dl
Assessment:
Admittance diagnosis: Upper GI Bleed, Cirrhosis
• Anthropometric:
◦ 57 year old male
◦ Previous visit (6/17) vitals:
▪ 5' 7”, 194 # (BMI: 30.4- obese)
▪ BP 128/80- slightly high
▪ Pulse 90-normal
▪ RR 16- higher end of normal
▪ Temp 98.9- normal
*No recorded 7/1 or 7/11 vitals
Biochemical Indicators
(7/1): Na (low), CO2 (low), Creatinine (high), PTT (high), Hgb (low), Hct (low), Albumin (low).
• Physical
◦ Stabilized
◦ Diagnosis: Chronic alcoholic cirrhosis with stable encephalopathy and esophageal
varices.
• Medical History
◦ Hypertension
◦ Cholecystectomy
◦ Alcoholism
◦ Medications at home: TUMS, Zantac, Lisinopril
• Hospital medications: Lactulose, Octreotide, Vitamin K, Compazine, Morphine, albumin
iv, furosamide iv
• (7/1): Tri-luminal catheter, TPN with Hepatamine® (limit 1500 ml).
• Social/Family History
◦ Divorced for 15 years.
◦ Mother living but father died at age 65 from CHF

7. ◦ Living siblings: Brother 53 has atherosclerotic heart disease
▪ Brother 40 and sister 46 in apparent good health
▪ Sister age 48 is obese
• Previous diet history
◦ 6/17:
▪ High calories coming from 7 shots of bourbon/day and 6 beers/day
▪ High calories, saturated fats, and sodium coming from processed foods (hot dog,
chips, condiments, pasta/macaroni and cheese
▪ Low intake (if at all) of fruits and vegetables
▪ Low protein consumption
◦ 7/1:
▪ Tri-luminal catheter, TPN with Hepatamine® (limit 1500 ml).
◦ 7/11- diet prescription:
▪ TPN tapered and patient diet order changed to clear liquid progressing to oral diet
as tolerated. Fluid restricted to 2000 ml/day, 2300 mg sodium, soft diet.
Diagnosis:
1) Intake Domain: Malnutrition R/T diagnosis of chronic alcoholic cirrhosis AEB increased
creatinine and albumin levels (on 7/1) and previous TPN administration
Intervention:
• Discuss with the patient the importance of a balanced diet (once tolerated)
• Educate the patient about the harmful effects of alcoholism on his body
• Have the client come up with healthy foods to incorporate into his day
• Encourage the client to keep a food/fluid record for future analysis
Follow-up:
• Analyze the patient's food and fluid record (see if it meets the fluid and sodium
recommendations)
• Monitor creatinine levels
• Assess patient's tolerance to transition to soft oral diet
2) Clinical Domain: Altered GI function R/T diagnosis of chronic alcoholic cirrhosis AEB
increased abdominal girth secondary to ascites.
Intervention:
• Encourage client to decrease alcohol consumption (or quit all together)
• Encourage client to consume a balanced diet (as tolerated) and to keep a
food/fluid diary

8. • Encourage client eat smaller more frequent meals to avoid further symptoms of
GERD.
Follow-up:
• Assess the client’s compliance to decreasing/quitting alcohol consumption
• Analyze food and fluid diary
• Monitor lab values of concern: (7/1): Na (low), CO2 (low), Creatinine (high), PTT
(high), Hgb (low), Hct (low), Albumin (low).
3) Behavioral Domain: Undesirable food choices R/T excessive alcohol consumption,
sodium, and fat intake AEB dietary recall provided in admittance.
Intervention:
• Educate client about the effects of alcoholism
• Encourage client to come up with healthy meal/snack choices
• Assess the client’s ability to cook and give ideas of unprocessed meals to make
• Encourage activities/hobbies to take the place of drinking during the day
Follow-up:
• Assess the client’s compliance in decreasing/quitting excessive alcohol
consumption
• Assess the client’s progress in making healthier unprocessed meals
• Assess the client’s knowledge about healthy food options to consume
• Assess the client’s progress in choosing activities to prevent excess alcohol
consumption.