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CASE STUDY

CASE STUDY. Cirrhosis Elizabeth Olivares April 7, 2014. Introduction. The purpose of this case study is to explain the medical care and treatment provided to the patient. Medical Nutrition Therapy Assess nutritional needs Provide Nutrition Education Materials and Diet Therapy

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CASE STUDY

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  1. CASE STUDY Cirrhosis Elizabeth Olivares April 7, 2014

  2. Introduction • The purpose of this case study is to explain the medical care and treatment provided to the patient. • Medical Nutrition Therapy • Assess nutritional needs • Provide Nutrition Education Materials and Diet Therapy • Vitamin Therapy and Nutrition Supplement Recommendations • Monitor Progress • Patient admitted 2/3/2014 • Recently dx w/ cirrhosis of an unknown etiology. • Admitted w/ abdominal pain, SOB, and abdominal distention. • Bilateral stage 2 pressure ulcer on buttocks. • Discharged 2/9/2014 clinically stable condition. • Referred to home health • Followed by Gastroenterologist .

  3. Test Your Knowledge What is Cirrhosis? Answer: Chronic disease. Scarring of the liver that impedes the organ from functioning normally.

  4. Cirrhosis • End-stage liver disease means the liver no longer has the ability to perform its functions (3). • Injury can occur from a single event (hepatitis) or over years due to alcoholism or chronic hepatitis(3). • Scar tissue forms as a response to liver cell damage (3). • Compress veins within the liver • Cause portal hypertension: high pressures within blood vessels of the liver (3). • Cirrhosis is a common cause of portal hypertension • Can cause "bleeding into the intestines and fluid accumulation throughout the body“ (3).

  5. Cirrhosis • The third most common cause of death in people aged 45-65 years in the U.S. (3). • It is estimated that 25,000 people die of cirrhosis in the U.S. each year (3). • Etiology of cirrhosis can stem from: • Chronic alcoholism • Hepatitis • Biliary cirrhosis • Autoimmune cirrhosis • Nonalcoholic fatty liver • Inherited diseases • Drugs • Toxins • Infections • Cardiac cirrhosis (patient’s w/ right sided heart failure) (3).

  6. Symptoms Early Stages Occur w/ Complications • Caused by gradual failure of the liver to carry out its natural functions Or • Distortion of the liver's usual shape and size because of scarring" (3). • Fatigue • Weakness • Nausea • Loss of appetite leading to weight loss • Loss of sex drive • Jaundice • Vomiting • Diarrhea • Itching • Abdominal pain • Swelling or bloating • Weight gain • Edema • SOB • Sensitivity to medication • Confusion • Coma • Gum or nose bleed, bloody emesis or stool • Hemorrhoids • Loss of muscle mass • Abnormal menses in women • Enlargement of breast and genitals in men" (3).

  7. Test Your Knowledge What can patients do to slow the progression of cirrhosis? Answer: • Stop drinking alcohol. • Avoiding liver harming medications. • Following low sodium diet. • Eating balanced diet with adequate calories and protein (3).

  8. Treatment • No cure • Slow the progression • A liver transplant is the only way to improve chances of survival and "80-90%" of transplants are successful (3). Medical treatments • Used to treat or manage complications • Steroids and anti-inflammatory agent do not prolong survival includes (3). • Beta-blocker medication can to lower the pressure to treat portal hypertension (3). • Diuretic help remove excess fluid retention (3). • Lactulose may be prescribed to "reduce the amounts of toxins absorbed into your intestinal tract" and patient would be recommended a low protein diet (3).

  9. Prognosis Model for End-stage Liver Disease • A reliable measure of mortality risk in patients with end-stage liver disease (6). • Used as a disease severity index to help prioritize allocation of organs for transplant (6). • MELD Score = 0.957 x Loge(creatinine mg/dL) + 0. 378 x Loge(bilirubin mg/dL) + 1.120 x Loge (INR) + 0.643

  10. Patient • 68 year old • Caucasian • Male • Retired • Married • Support system: Wife and Children • Current smoker • ½ pack/day x 52 years • Social drinker • Past Medical Hx • Cirrhosis w/ lobular inflammation (dx 12/2013) • Insulin Dependent Diabetic • GERD • HTN • CAD • Acute Renal Failure • Prostatic Hyperplasia • Degenerative Joint Disease • Carpal Tunnel • Past Surgical Hx • Coronary Artery Bypass Graft x 4 • Transurethral resection of the prostate • Tonsillectomy, appendectomy, knee surgery, bilateral carpal tunnel surgery

  11. Nutrition Screening • Critical Care Unit: • Admitted for decompensated hepatic cirrhosis with evidence of portal hypertension, hypoalbuminemia, thrombocytopenia, severe ascites, and Model for End-stage Liver Disease (MELD) scores from 25-30. • Recent Diagnosis of Cirrhosis • Bilateral stage 2 pressure ulcer on buttocks • Hyperkalemia • H&P: “loss of appetite and nausea” Patient Interviewed: determine appetite, oral intake and GI symptoms. • Fair appetite (usually great), no nausea or vomiting, but did have episode of diarrhea. • Patient desired that his wife to be given education for his dietary needs.

  12. Test Your Knowledge What lab values would you expect to be out of range in a patient w/ Cirrhosis? • Answer: • Liver Function Tests (LFT’s) • ALK PHOS • ALT • AST • Bilirubin • Albumin

  13. Labs

  14. Medications

  15. Test Your Knowledge What is a paracentesis? • Answer: a procedure to remove fluid buildup (ascites) that has collected in the abdomen (peritoneal fluid).

  16. Plan of Care MD and Nursing Procedure • MD notes patients health status declining from cirrhosis standpoint w/ ascites and signs of decompensation. • Supportative Care • Followed by Gastroenterologist • Not a candidate for transplant Treat • Ascites (Bumex drip) • Hyperkalemia (discontinue K+ suppplement & Aldactone) • Elevated Ammonia levels (given lactulose causing diarrhea) Monitor • Hyponatremia (fluid overload) • Acute Renal Failure • Hyperbilirubinemia (causing severe itching) • Liver Function Tests (LFT’s) • Paracentesis • Two procedures • Remove a total of 7.5 liters of fluid (7.5 kg = 16.5 lbs) • Developed secondary bacterial peritonitis • Treated w/ antibiotics • Acute renal failure

  17. Assessment Anthropometrics • Ht: 175.3 cm (5’9”) • Wt: 109 kg (239.8 lbs) • BMI: 35.47 kg/m2 (Obese class II) • IBW: 72.7 kg (160 lbs) • %IBW: 149 % • ABW: 86.4 kg (190 lbs) Weight hx in Hospital: • 2/4 109 kg (238 lbs) • 2/6 112.9 kg (248 lbs) • 2/7 110.8 (244 lbs)

  18. Test Your Knowledge What diet recommendations would you recommend with the patients current disease conditions? Answer: • High Calorie • High Protein • Low Sodium • (Lower protein if ammonia levels continue to be elevated).

  19. Nutrient Requirements • Calories (MSJ x 1.2-1.5 SF): 2220-2775 kcals/day • Protein (1.0-1.5 gm/kg ABW): 86-130 gm/day • Fluid: per MD due to ascites 24 Hour Recall: Hospital Food

  20. Nutrition Interventions • Recommended reinitiating a MVI/MIN supplement & initiate 250 mg of Vitamin C x 1 month to promote healing of bilateral pressure ulcers on buttocks. • Recommended adding Beneprotein supplement TID w/ meals to provide additional grams of protein. Provided patient's spouse and children w/ • Cirrhosis Nutrition Therapy Handout • Salt Savvy • High Calorie and High Protein Nutrition Therapy Handout with review

  21. Diet Order Patient had good appetite during hospital stay consuming 75-100% of meals. Tolerated Beneprotein.

  22. Prognosis • Model for End-stage Liver Disease • Patient’s Score: 25-30

  23. Conclusion • Patient admitted with abdominal pain, ascites, & SOB. • RD screened for cirrhosis diagnosis. • Two paracentesis done to remove a total of 7.5 liters of fluid. • Hyperkalemia upon admit & placed 2 gm K+ diet. • Diet was liberalized after K+ levels were WNL. • Placed on lactulose due to rising ammonia levels, causing diarrhea. • Added Beneprotein supplement TID with meals to increase protein intake, Provided Cirrhosis Nutrition Therapy, Salt Savvy, and High Calorie/High Protein w/ handouts patient’s wife & recommended vitamin therapy to promote pressure ulcer healing. • MELD score of 25-30; ~78 % chance of surviving 6 months,~71% chance of surviving 1 year and ~66% chance surviving 2 years (1,5). •  Patient discharged home (LOS 7 days), referred to Providence home health, and was to follow up w/ gastroenterologist.

  24. References • Kim HJ and Lee HW. Important predictor of mortality in patients with end-stage liver disease. US National Library of MedicineNational Institutes of Health Website. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3701842/. Accessed March 1, 2014. • Health Central. Atelectasis. Health Central Website. Available at: http://www.healthcentral.com/encyclopedia/408/440.html. Accessed on March 1, 2014. • EMedicineHealth. Cirrhosis. EMedicineHealth Website. Available at: http://www.emedicinehealth.com/cirrhosis/article_em.htm. Accessed March 1, 2014. • Dolan B and Robert Arnold R. # 189 Prognosis in Decompensated Chronic Liver Failure. EPERC Website. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_189.htm. Accessed March 1, 2014. • Cox-North P, Doorenbos A, Shannon SE, Scott J, and Curtis JR. The Transition to End-of-Life Care in End-stage Liver Disease. Medscape Website. Journal of Hospice and Palliative Nursing. 2013;15(4):209-215.  Available at: http://www.medscape.com/viewarticle/804461. Accessed March 1, 2014. • Mayo Clinic. Model End- stage Liver Disease. Mayo Clinic Website. Available at: http://www.mayoclinic.org/medical-professionals/model-end-stage-liver-disease. Accessed March 1, 2014. • Google. Google Images. Google Website. Available at: googleimage.com. Accessed March 15, 2014.

  25. Questions?

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