The patient, a 57-year-old male with a history of alcoholism and cirrhosis, was admitted with upper GI bleeding and esophageal varices. He underwent placement of a surgical jejunostomy tube due to his bleeding varices. His condition deteriorated, requiring transfer to the ICU and initiation of TPN using Hepatamine to provide nutrition support and manage his liver disease. He was later transitioned to a clear liquid diet and discharged on a soft diet with fluid restrictions and electrolyte management.

1. End Stage Liver Disease with GERD and Bleeding Esophageal Varices
FSHN 450
Fall 2015
Admission Data: 57 year old male admitted from ES c/o N&V, and abdominal pain radiating to Rt
side. Patient presented with scleral icterus, increased abdominal girth secondary to ascites, black
stools.
Current Dx: Upper GI Bleed, Cirrhosis
MedHx: Htn, cholecystectomy, alcoholism
Social: 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.
Medications at home: TUMS, Zantac, Lisinopril
Medications: Lactulose, Octreotide, Vitamin K, Compazine, Morphine, albumin iv, furosamide iv
Physical: Ht. 5'7” Current BW 190 # BP 128/80 Pulse 90 RR 16 Temp 98.9
Hospital Course:
6/17 Admission Laboratory:
Na 120 mEq/L
K 4.7 mEq/L
Cl 87 mEq/L
CO2 19.3 mmol/L
Glu 91 mg/dl
BUN 13 mg/dl
Creat 1.6 mg/dl
PTT 43.1 seconds (reference: 23.7 - 32.7 seconds)
RBC 2.88 x106
/mm3
Hgb 9.1g/dl
Hct 26.9 %
Albumin 2.3 g/dl
Triglycerides 325 mg/dl
Total Cholesterol 250 mg/dl
HDL-Cholesterol 40 mg/dl
Physical and Neurological Exam: 0 Asterixis 0 edema of extremities
Gastroscopic Examination showed bleeding esophageal varices

2. Diet History reveals the following usual intake:
8am 1 cup black coffee with 1 shot bourbon
10 am 1cup cornflakes with ½ c 2% milk
12 noon 1 hot dog on bun with relish and mustard
2 cans beer
30 potato chips
2 pm 1 snickers bar
Afternoon 3 shots bourbon
6 pm 1 cup pasta or baked macaroni and cheese
2 cans beer
Evening 2 cans beer
3 shots bourbon
6/28 Patients’s condition continues to deteriorate. Current BW : 194 pounds. Diet: NPO.
Surgical jejeunostomy tube placed and nutrition support consult ordered.
What was the cause of the weight gain????
What is the purpose of each of the patient’s medications? List any important
drug:nutrient interactions.
Why was a surgical jejeunostomy tube placed?
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.
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
Tube feeding is not well tolerated. Patient disoriented to time and place. Mild asterixis and 2+
edema present. Patient transferred to ICU. Tri-luminal catheter placed and nutrition support consult

3. ordered for TPN with Hepatamine®, limit 1500 ml.
List the probably reasons for the tube feeding intolerance in this patient?
You do not need to calculate a TPN but you should reevaluate protein and Kcal needs.
Why was Hepatamine® ordered and what at is the drawback to using this product?
7/11 Patient stabilized. 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. Prepare to
discharge to home. Dx: chronic alcoholic cirrhosis with stable encephalopathy and esophageal
varices.
Why was a soft diet ordered?
Conduct a follow-up nutrition assessment and report in ADIME format for
transition to oral diet (on 7/11)
Develop three PES statements, one in each domain and plan an itervention and
follow-up for each nutrition diagnosis.
*** DO NOT forget to answer all the questions in bold.

4. What is the cause of weight gain?
• Ascites is the major contributor to weight gain due to fluid retention in the abdomen.
• The cause of weight gain prior to admission was largely from the amount of alcohol the
patient is consuming. One gram of alcohol is equivalent to 7 kcals. The patient is
consuming the majority of calories from alcohol and the calories consumed via food are
low nutrient dense and higher in saturated fats and processed foods, also contributing to
weight gain.
What is the purpose of each of the patient’s medications? List any important drug:nutrient
interactions.
• TUMS: antacid, calcium carbonate supplement, phosphate binder. Tums can treat
heartburn, acid indigestion, and upset stomach, which are associated with GERD. This
antacid can also be used to treat calcium deficiency related to malabsorption. Pt needs to
ensure adequate hydration and increase fluids with intake. Pt needs to take iron,
magnesium, or zinc separately by 1-2 hours because they may interfere with absorption.
Pt needs to increase vitamin D to maintain essential calcium and bone metabolism.
Caffeine may increase calcium excretion, which may need to be reduced in diet to ensure
adequate bone health.
• Zantac: Histamine H2 Receptor Antagonist, antiulcer, antigerd, antisecretory. This drug
decreased gastric acid secretions and increases gastric pH. Zantac is also used to treat of
prevent ulcers in the stomach or intestine. Pt needs to take with water (keep in mind fluid
restriction with hyponatremia). Pt needs to limit caffeine intake and take antacids
(TUMS) separately. This drug can decrease the absorption of iron and vitamin B12. Pt
needs to avoid alcohol with intake of Zantac. Caution should be taken with decreased
hepatic function.
• Lisinopril: Antihypertensive and Angiotensin Converting Enzyme (ACE) Inhibitor.
Lisinopril is taken to reduce high blood pressure. Pt needs to ensure adequate fluid intake
(keep in mind fluid restriction with hyponatremia). Lower sodium and a decrease in total
calories (lower consumption of alcohol because that is the main contributor of calories in
pt’s diet) may be recommended. Pt should avoid natural licorice. Caution should be taken
due to decreased hepatic function. May increase risk for pancreatitis and jaundice (or
worsen current condition).
• Lactulose: Laxative (hyperosmotic). This drug is a synthetic sugar used to treat
constipation. Lactulose is also taken to reduce the amount of ammonia in the blood. Pt
needs to take with water or mix with food to improve the taste. Pt needs to increase fiber
along with 1500-2000 ml of fluid/day to prevent constipation. Pt should not take
consistently with antacids. This drug may increase the absorption of calcium and
magnesium.
• Octreotide: Antidiarrheal and antiacromegaly used to treat bleeding esophageal varices to
be administered via PN. This drug should be injected between meals to decrease GI
effects. Pt would benefit from a diet lower in fat to reduce GI side effects. This drug may
cause malabsorption of fat and fat-soluble vitamins.
• Vitamin K: Fat-soluble vitamin that increases blood clotting and to treat
hypoprothrombinemia. This is given to decrease blood loss from the upper GI. Pt needs
to maintain consistent vitamin K intake and not consume a large dose. Caution with
vitamin E intake, as it will antagonize vitamin K action. Caution should be taken with

5. decreased hepatic function and pancreatic or intestinal disease may decrease vitamin K
absorption.
• Compazine: antiemetic, antinauseant, antipsychotic. This drug is taken in order to control
nausea and vomiting, as well as anxiety through sedation. Pt should consume with food,
milk, or water to decrease GI stress. Pt needs to limit caffeine intake, however this is
administered in the hospital, so there should be no consumption. Pt needs to avoid
alcohol and caution should be taken with decreased hepatic function. This drug has the
tendency to increase appetite and thus weight gain. May reduce the absorption of vitamin
B12. This drug can increase jaundice and edema.
• Morphine: analgesic, narcotic, opioid. Morphine is taken as a pain medication to reduce
the amount of pain the pt is feeling. Pt needs to ensure adequate hydration and fluid
intake and may need to take morphine with food to reduce GI distress. This drug can
increase dehydration and thirst. Pt needs to avoid alcohol because it increases the release
from SR beads, which is potentially fatal. Caution should be taken with decreased hepatic
function and may cause hypotension and edema.
• Albumin IV: albumin needs to be administered because laboratory values are low.
Reasons for low levels include hypovolemia due to blood loss, protein loss due to muscle
wasting and low intake/absorption. Albumin can help treat hyperbilirubinemia and
related jaundice by binding and removing excess bilirubin. This is an issue that needs to
be addressed due to cholecystectomy.
• Furosemide IV: diuretic (K-depleting), antihypertensive. This is used to treat edema and
ascites with liver disease as well as high blood pressure. Furosemide needs to be taken on
an empty stomach as food decreases the bioavailability. However, some patients benefit
with food if GI distress occurs. Pt should avoid natural licorice and limit alcohol. Caution
should be taken with decreased liver function. Due to the K depleting function of this
diuretic, pt needs to consume adequate K via diet.
Why was a surgical jejeunostomy tube placed?
• A surgical jejunostomy tube was placed because of the bleeding varices in the esophagus.
The extra blood flow in these veins causes a balloon effect and if a tube was inserted via
nasogastic tube, there is a higher chance of bleeding out and mortality.
Nutrition Assessment
Anthropometric Measurements
(6/17)
• 57 yo male. Admitted from ES. c/o N&V and abdominal pain on right side. Pt presented
with scleral icterus, increased abdominal girth secondary to ascites, and black stools
• Dx: upper GI bleed and cirrhosis
• Medical Hx: HTN, cholecystectomy, alcoholism
• Ht: 5’7” Wt: 190 lbs. BMI: (190 lbs./67 in2
) X 703 = 29.8 kg/m2
(close to class I obesity
BMI >30)
(6/28)
• Ht: 5’7” Wt: 194 lbs. (4lb weight gain) BMI: (194 lbs./67 in2
) X 703 = 30.4 kg/m2
(BMI
>30 = class I obese)
Biochemical Data, Medical Tests, and Procedures

6. • Gastroscopic exam revealed bleeding esophageal varices
• (6/28) surgical jejunostomy in place
Table of Relevant Physical and Laboratory Values
Patients Value Normal Range Explanation: Reason for
Variance
Asterixis: 0 No weakness or tremors Normal
Edema of extremities: 0 No swelling, redness, or
drainage and symmetrical
Normal
(6/17): Ht: 5’7” Wt: 190
lbs. BMI: (190 lbs./67 in2
)
X 703 = 29.8 kg/m2
(6/28) Ht: 5’7” Wt: 194
lbs. (4lb weight gain) BMI:
(194 lbs./67 in2
) X 703 =
30.4 kg/m2
18.5-24.9 (close to class I obesity
BMI >30: overweight)
(BMI >30 = class I obese)
BP: 128/80 120/80 Prehypertensive: systolic is
greater than 120 and lower
than 139. Diastolic: (80-89)
Pulse: 90 bpm 60-100 bpm Within normal range
RR: 16 breaths per min 12-16 breaths per min Within normal range
Temp: 98.9 98.6 Slightly elevated, not of
concern
Na: 120 mEq/L 136-144 mEq/L Decreased d/t
malabsorption, vomiting,
and intake of diuretic
K: 4.7 mEq/L 3.5-5.0 mEq/L Within normal range
Cl: 87 mEq/L 98-107 mEq/L Decreased d/t metabolic
alkalosis (Zantac),
vomiting, and possible
acute infections
CO2: 19.3 mEq/L 22-29 mEq/L Decreased d/t vomiting and
metabolic alkalosis (Zantac)
Glu: 91 mg/dl 70-99 mg/dl (fasting)
<180 mg/dl pp
Within normal range
BUN 13 mg/dl 8-23 mg/dl Within normal range
Creat: 1.6 mg/dl 0.4-1.2 mg/dl Elevated d/t muscle wasting
PTT: 43.1 seconds 23.7 -32.7 seconds Elevated d/t hepatic disease
RBC: 2.88 X106
/mm3
4.7-6.1 X106
/mm3
Decresed d/t iron deficiency
and possible anemia
Hgb: 9.1 g/dl 14.6-17.5 g/dl Decreased d/t cirrhosis and
possible anemia
(malabsorption of iron)

7. Hct: 26.9% 34-45% Decreased d/t blood loss in
upper GI and cirrhosis
Albumin: 2.3 g/dl 3.5-5.0 g/dl Decreased d/t hepatic
disease, malabsorption,
upper GI bleed, edema
(inability to synthesize
albumin), malnutrition, and
stress
Triglycerides: 325 mg/dl Desirable: <150 mg/dl Elevated (high: 200-499
mg/dl) d/t hepatic disease,
alcoholism, and high
sugar/fat intake
Total Cholesterol: 250
mg/dl
120-199 mg/dl >240 mg/dl = high risk:
elevated d/t alcohol intake,
hyperlipidemia, and
jaundice (scleral icterus)
HDL-C: 40 mg/dl Low: <40 mg/dl
High: >60 mg/dl
On the lower range d/t
alcohol intake
Nutrition Focused Physical Findings
• 6/28: NPO and surgical jejunostomy in place d/t bleeding esophageal varices
• N&V, abdominal pain on right side
• Scleral icterus (jaundice d/t loss of gallbladder)
• Increased abdominal girth d/t ascites
• Black stools d/t upper GI bleed
• Current dx: upper GI bleed, cirrhosis
• Medical hx: HTN, cholecystectomy, alcoholism
• Medications at home: TUMS, Zantac, Lisinopril
• Medications in hospital: Lactulose, Octreotide, Vitamin K, Compazine, Morphine,
Albumin IV, Furosemide IV
Food/Nutrition Related Hx
• 24-hour diet intake:
o High alcohol intake: 1 shot of bourbon in am, 2 cans of beer at lunch, 3 shots of
bourbon in afternoon, 2 cans of beer at dinner, 2 cans of beer and 3 shots of
bourbon at night.
o Low nutritional quality/highly processed/increased sodium intake: hot dog on bun
with relish and mustard, potato chips, snickers bar, pasta or baked macaroni and
cheese
o Moderate high saturated and trans fat intake: hot dog, potato chips, snickers bar
o Moderate protein intake: milk in am, peanuts in snickers bar, and cheese with
macaroni
o Pt is not consuming water. Needs to increase but keep in restrictive range (1.5-2
L/day)

8. • Est. Energy Requirement: 32-33 kcal/Kg Body Weight/day; higher intake due to
hypermetabolic state and intended to prevent malnutrition:
o 32 kcal X 88.2 Kg= 2,822.4 kcal/Kg
o 33 kcal X 88.2 Kg= 2,910.6 kcal/Kg
o Range: 2,822.4 – 2,910.6 kcal/Kg/day
• Est. Protein Intake: 1.2-1.4 g/Kg Body Weight (using 194 lbs or 88.2 Kg): no
neurological signs of Hepatic Encephalopathy, pt is clinically stable. Should be slightly
higher than normal d/t GI bleeds and ascites. Protein should be increased in branched
chain amino acids (BCAA) rather than aromatic amino acids (AAA) to reduce the uptake
of AAA into the brain.
o 1.2 g Pro X 88.2 Kg = 105.8 g Protein/day
o 1.4 g Pro X 88.2 Kg = 123.5 g Protein/day
o Range: 105.8 – 123.5 grams of Protein/day
• Est. Fluid Intake: Pt is placed on fluid restriction based on hyponatremia2
and present
ascites.
o 1.5 – 2 L/day
• Prescribed tube feed: Nestlé’s NutriHep product. Formulated to decrease metabolic-end
products in patients with hepatic disease.3
Higher ration of BCAA to AAA.3
Caloric
dense for fluid management.3
Higher MCT than LCT to facilitate absorption.3
o 1.5 kcal/ml
o 77% CHO
o 11% Fat, mostly MCTs
o 12 % Protein
o Administration: continuous drip infusion because the patient is being fed into the
small intestine
o (2,822.4 kcals / 1.5 kcal/ml) = 1,881.6 ml
o (2,910.6 kcals/ 1.5 kcal/ml) = 1,940.4 ml
o Average ml/day: 1,881.6 + 1,940.4 = 3,822 ml/2 = 1,911 ml = Total Volume
o 1,911ml / (24 hours per day of administration) = 80 ml/hour = Goal Rate
o Start rate: ¼ goal rate
§ 80 ml X 0.25 = 20 ml/hr
o Progression: Advance by 20 ml every 8-12 hours to meet the final volume
Client Hx
• Current dx: Upper GI bleed, cirrhosis
• Medical hx: HTN, cholecystectomy, alcoholism
• c/o N&V, abdominal pain radiating to right side
• scleral icterus, increased abdominal girth secondary to ascites, black stools (d/t bleeding)
• Divorced for past 15 years
• Pt’s mother is living
• Father died at 65 years of age from CHF
• 4 living siblings:
o Brother: 53 yo has atherosclerotic heart disease
o Brother 40 yo and sister 46 yo in good health
o Sister 48 yo is obese

9. List the possible reasons for the tube feeding intolerance in this patient.
• Patient has progressed to stage 2 hepatic encephalopathy
• Due to the patient’s condition of irreversible cirrhosis and an upper GI bleed, the fat
contained in the tube feed is directed to the liver via the hepatic portal vein. The liver has
an impaired release of VLDL and thus, increases the fat content in the liver, which is not
easily tolerated. Furthermore, the nutrients are not being absorbed in adequate amounts
because of the upper GI bleed.
• According to laboratory values (7/1) the pt has low electrolyte levels due to nausea and
vomiting. Also, formulas intended for use in hepatic failure are intentionally low in
specific vitamins, mineral, and electrolytes.1
Due to the patient’s current symptoms of
N/V, the tube feed may have made this worse.
• The tube feed may also have caused distention, bloating, or cramping in the abdomen.
The patient already has abdominal girth with ascites as well as abdominal pain, and the
tube feed may have made this condition worse.
Reevaluate protein and Kcal needs.
• Due to Grade 2 encephalopathy, pt should receive 0.8 g Pro/Kg – 0.9 g Pro/Kg
o 0.8 g Pro X 88.2 Kg = 70.56 g Pro/Kg
o 0.9 g Pro X 88.2 Kg = 79.38 g Pro/Kg
o Range: (70.56 – 79.38 g Protein/ day)
• Est. Energy Requirement: 32-33 kcal/Kg Body Weight/day: same recommendation as
before to prevent malnutrition
o 32 kcal X 88.2 Kg= 2,822.4 kcal/Kg
o 33 kcal X 88.2 Kg= 2,910.6 kcal/Kg
o Range: 2,822.4 – 2,910.6 kcal/Kg/day
Why was Hepatamine ordered and what is the draw back of using this product?
• Hepatamine was ordered to reverse stage 2 encephalopathy. Hepatamine is higher in
branched chain amino acids (BCAA) and lower in aromatic amino acids (AAA), which
helps reduce the amount of AAA entering into the brain and thus reduce the amount of
ammonia in the body. The draw back of using this product is that it requires a high
volume (2,000 ml) and has the lowest protein. Since the patient is receiving 1,500 ml, the
patient will be close to meeting their required protein intake.
Why was a soft diet ordered?
• A soft diet was ordered to prevent bleeding of esophageal varices. Softer foods are easier
to swallow and digest.
Follow-up Nutrition Assessment: Transition to Oral Diet (7/11)
Anthropometric Measurements
(6/17)
• 57 yo male. Admitted from ES. c/o N&V and abdominal pain on right side. Pt presented
with scleral icterus, increased abdominal girth secondary to ascites, and black stools
• Dx: upper GI bleed and cirrhosis
• Medical Hx: HTN, cholecystectomy, alcoholism

10. • Ht: 5’7” Wt: 190 lbs. BMI: (190 lbs./67 in2
) X 703 = 29.8 kg/m2
(close to class I obesity
BMI >30)
• (6/28) Ht: 5’7” Wt: 194 lbs. (4lb weight gain) BMI: (194 lbs./67 in2
) X 703 = 30.4 kg/m2
(BMI >30 = class I obese)
(7/1)
• Mild asterixis and 2+ edema present
(6/28)
• Ht: 5’7” Wt: 194 lbs. (4lb weight gain) BMI: (194 lbs./67 in2
) X 703 = 30.4 kg/m2
(BMI
>30 = class I obese)
(7/11)
• Dx: chronic alcoholic cirrhosis with stable encephalopathy and esophageal varices
• Prepared to discharge
Biochemical Data, Medical Tests, and Procedures
(7/1) Table of Relevant Laboratory Values
Patients Value Normal Range Explanation: Reason for
Variance
Na: 122 mEq/L 136-144 mEq/L Decreased d/t
malabsorption, vomiting,
and intake of diuretic
K: 4.1 mEq/L 3.5-5.0 mEq/L Within normal range
Cl: 98 mEq/L 98-107 mEq/L Within normal range
CO2: 10 mEq/L 22-29 mEq/L Decreased d/t vomiting
and metabolic alkalosis
(Zantac)
Glu: 93 mg/dl 70-99 mg/dl (fasting)
<180 mg/dl pp
Within normal range
BUN 18 mg/dl 8-23 mg/dl Within normal range
Creat: 1.6 mg/dl 0.4-1.2 mg/dl Elevated d/t muscle
wasting
PTT: 43.1 seconds 23.7 -32.7 seconds Elevated d/t hepatic
disease
RBC: 2.88 X106
/mm3
4.7-6.1 X106
/mm3
Decresed d/t iron
deficiency and possible
anemia
Hgb: 9.1 g/dl 14.6-17.5 g/dl Decreased d/t cirrhosis
and possible anemia
(malabsorption of iron)
Hct: 26.9% 34-45% Decreased d/t blood loss
in upper GI and cirrhosis
Albumin: 2.6 g/dl 3.5-5.0 g/dl Decreased d/t hepatic
disease, malabsorption,
upper GI bleed, edema
(inability to synthesize

11. albumin), malnutrition,
and stress
Nutrition Focused Physical Findings
(6/17)
• N&V, abdominal pain on right side
• Scleral icterus (jaundice d/t loss of gallbladder)
• Increased abdominal girth d/t ascites
• Black stools d/t upper GI bleed
• Current dx: upper GI bleed, cirrhosis
• Medical hx: HTN, cholecystectomy, alcoholism
• Medications at home: TUMS, Zantac, Lisinopril
• Medications in hospital: Lactulose, Octreotide, Vitamin K, Compazine, Morphine,
Albumin IV, Furosemide IV
(6/28)
• NPO and surgical jejunostomy in place d/t bleeding esophageal varices
(7/1)
• Tube feeding not well tolerated: patient disoriented to time and place.
• Mild asterixis and 2+ edema present
• Transferred to ICU
• Tri-luminal catheter placed and nutrition support consult ordered
• Heptamine at 1500 ml
(7/11)
• TPN tapered and pt diet order changed to clear liquid progressing to oral diet as
tolerated
• Patient stabilized: prepare to discharge
Food/Nutrition Related Hx
(6/17)
• 24-hour diet intake:
o High alcohol intake: 1 shot of bourbon in am, 2 cans of beer at lunch, 3 shots of
bourbon in afternoon, 2 cans of beer at dinner, 2 cans of beer and 3 shots of
bourbon at night.
o Low nutritional quality/highly processed/increased sodium intake: hot dog on bun
with relish and mustard, potato chips, snickers bar, pasta or baked macaroni and
cheese
o Moderate high saturated and trans fat intake: hot dog, potato chips, snickers bar
o Moderate protein intake: milk in am, peanuts in snickers bar, and cheese with
macaroni
o Pt is not consuming water. Needs to increase but keep in restrictive range (1.5-2
L/day)
• Est. Energy Requirement: 32-33 kcal/Kg Body Weight/day; higher intake due to
hypermetabolic state and intended to prevent malnutrition:
o 32 kcal X 88.2 Kg= 2,822.4 kcal/Kg
o 33 kcal X 88.2 Kg= 2,910.6 kcal/Kg

12. o Range: 2,822.4 – 2,910.6 kcal/Kg/day
• Est. Protein Intake: 1.2-1.4 g/Kg Body Weight (using 194 lbs or 88.2 Kg): no
neurological signs of Hepatic Encephalopathy, pt is clinically stable. Should be slightly
higher than normal d/t GI bleeds and ascites. Protein should be increased in branched
chain amino acids (BCAA) rather than aromatic amino acids (AAA) to reduce the uptake
of AAA into the brain.
o 1.2 g Pro X 88.2 Kg = 105.8 g Protein/day
o 1.4 g Pro X 88.2 Kg = 123.5 g Protein/day
o Range: 105.8 – 123.5 grams of Protein/day
• Est. Fluid Intake: Pt is placed on fluid restriction based on hyponatremia2
and present
ascites.
o 1.5 – 2 L/day
• Prescribed tube feed: Nestlé’s NutriHep product. Formulated to decrease metabolic-end
products in patients with hepatic disease.3
Higher ration of BCAA to AAA.3
Caloric
dense for fluid management.3
Higher MCT than LCT to facilitate absorption.3
o 1.5 kcal/ml
o 77% CHO
o 11% Fat, mostly MCTs
o 12 % Protein
o Administration: continuous drip infusion because the patient is being fed into the
small intestine
o (2,822.4 kcals / 1.5 kcal/ml) = 1,881.6 ml
o (2,910.6 kcals/ 1.5 kcal/ml) = 1,940.4 ml
o Average ml/day: 1,881.6 + 1,940.4 = 3,822 ml/2 = 1,911 ml = Total Volume
o 1,911ml / (24 hours per day of administration) = 80 ml/hour = Goal Rate
o Start rate: ¼ goal rate
§ 80 ml X 0.25 = 20 ml/hr
o Progression: Advance by 20 ml every 8-12 hours to meet the final volume
(6/28)
• NPO, condition is deteriorating
(7/1)
• Tube feed not well tolerated
• TPN with Heptamine, limit 1500 ml
(7/11)
• Fluid restricted to 2 L/day
• 2300 mg sodium
• soft diet
Client Hx
(6/17)
• Current dx: Upper GI bleed, cirrhosis
• Medical hx: HTN, cholecystectomy, alcoholism
• c/o N&V, abdominal pain radiating to right side
• scleral icterus, increased abdominal girth secondary to ascites, black stools (d/t bleeding)
• Divorced for past 15 years
• Pt’s mother is living

13. • Father died at 65 years of age from CHF
• 4 living siblings:
o Brother: 53 yo has atherosclerotic heart disease
o Brother 40 yo and sister 46 yo in good health
o Sister 48 yo is obese
(6/28)
• NPO and nutrition consult ordered: surgical jejunostomy placed
(7/1)
• Pt transferred to ICU: nutrition consult was ordered for TPN
(7/11)
• Prepare to discharge to home
• DX: chronic alcoholic cirrhosis with stable encephalopathy and esophageal varices
Diagnosis:
Clinical:
Altered nutrition-related laboratory value r/t alcoholic cirrhosis AEB albumin 2.6 g/dl.
Intervention
• Counsel pt on importance of incorporating vegetable based protein in diet, due to the
higher concentration of BCAA. Encourage consumption of protein in recommended
amount.
Monitor/Evaluation
• Request lab values at next counseling session and evaluate levels of albumin.
• Assess understanding of incorporating adequate protein in diet if levels still remain low.
Intake:
Malnutrition r/t alcoholic cirrhosis AEB low clinical laboratory values of electrolytes
(sodium and chloride) and low nutrient dense foods in 24-hour diet.
Intervention
• I would recommend that the pt take vitamin and mineral supplements to prevent
deficiency, especially fat-soluble vitamins due to the inability of the liver to store.
• Educate the patient on the benefits of consuming adequate vitamins and minerals
and encourage increased consumption of nutrient dense foods. I would provide a list
of foods that the patient should include in his diet, following a soft diet and ensuring
that sodium intake is around 2300 mg/day.
Monitor/Evaluation
• Request lab values at next counseling session and evaluate levels of albumin.
• Request 24-hour diet recall to evaluate changes in intake. I would look for more
nutrient dense foods and assess understanding of the importance of vitamins and
minerals in diet.

14. Behavioral:
Undesirable food choices r/t alcoholism and consumption of empty calories AEB patient’s
24-hour diet recall upon admission.
Intervention
• I would counsel the pt on the importance of incorporating cooked fruits and
vegetables into his diet. Promoting the importance of soft food diet to not risk rupture
of esophageal varices.
• I would counsel the pt on the importance of making more desirable food choices
that contribute to a balanced diet.
• Furthermore, focusing on vegetable protein rather than meat protein because it is
better tolerated. I would provide the pt with a sample meal plan in order to promote
adequate calorie and protein intake to reverse malnutrition. This meal plan should be
fluid restricted (2L) and sodium restricted (2300 mg).
Monitor/Evaluation
• I would ask for a 24-hour diet recall during our next counseling session in order to
evaluate more desirable food choices.
References
1. Mahan LK. Nutrition Diagnosis and Intervention. In: Krause's Food &Amp; The
Nutrition Care Process. 13th ed. St. Louis, Mo.: Elsevier/Saunders; 2012: 618–624.
2. Harris M. Liver Disease. [PowerPoint]. Fort Collins, CO: CSU Food Science and Human
Nutrition Program; 2015.
3. Nutrihep. Nestle Health Science Web site.
https://www.nestlehealthscience.us/brands/nutrihep/nutrihep. Accessed November 4,
2015.