Kelsey Conrad Annelise Chmelik September 24 2013 the Liver Largest organ in the body Extremely complex organ Filters harmful substances from the blood Makes substances that digests food ID: 460871
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Slide1
Cirrhosis of the Liver
Kelsey Conrad
Annelise
Chmelik
September 24, 2013Slide2
the Liver
Largest organ in the body
Extremely complex organ
Filters harmful substances from the blood
Makes substances that digests food
Plays an important role in nutrient metabolismSlide3
Cirrhosis of the Liver
Healthy tissue in the liver is replaced by scar tissue
Blocks the flow of blood through the organ
Results in the loss of liver function
Most common causes
Chronic HCV
Alcoholism
Genetic factors can increase susceptibilitySlide4
Cirrhosis of the Liver
Enlarged liver resulting from fat accumulation and necrosis of the liver cells
Symptoms
Fatigue, weakness, nausea, poor appetite, and malaise.
Jaundice, dark urine, light stools,
steatorrhea
, itching, abdominal pain, and bloating.
Protein-energy malnutrition
Inability to consume adequate amounts of food
Impaired nutrient absorption and digestion
Vasodilation and expanded blood volumeSlide5
Cirrhosis of the Liver
Vitamin and mineral deficiencies
Related to decreased hematocrit and hemoglobin
values
Hypoglycemia
Liver is the key to glucose homeostasis
Altered liver function limits the ability to maintain normal glucose homeostasis
Disrupts hepatic glucose output
Can affect nutritional statusSlide6
Cirrhosis of the Liver
Bruising and bleeding
Related to decreased vitamin K absorption and ability to synthesize protein clotting factors.
Complications
Portal hypertension, hepatic encephalopathy, ascites,
hepatorenal
syndrome, and esophageal
varices
Treatment
Abstention from alcohol
Treatment of the complications
Nutrition therapySlide7
Cirrhosis of the Liver
MELD Score
Prognosis Model for End-stage Liver Disease
Clinical tool used to determine prognosis in patients with cirrhosis.
Based on three blood tests
INR – International normalized ratio
Bilirubin
Creatinine
Estimates an individual’s 90-day mortality rateSlide8
Cirrhosis of the Liver
Nutrition Therapy
Calorie recommendations – 35 to 40 kcal/kg per day
Protein intake – Up to 1.6 g/kg per day
Vegetable and dairy sources recommended for patients with mild encephalopathy
30% or less of total calories from fat
Carbohydrate consumed throughout the day
Restrict sodium
Consider enteral and parenteral support
Mechanically soft diet for patients with esophageal
varicesSlide9
Teresa Wilcox
26 year old female architecture doctoral student
Single – Lives with roommate Kevin
Gustat
Teaches late morning and late afternoon; takes classes and conducts research during most evenings.
Hepatitis C
Dx
3 years agoSlide10
Teresa Wilcox
Height – 5’8’’
Weight – 125
lbs
BP – 102/65
Reports alcohol use
Complains of fatigue, anorexia, nausea, vomiting, weakness, and bruising unrelated to injury.
Has lost 10
lbs
since last visit 6 months ago
Noted as a “tired looking young female”.Slide11
Medical Diagnosis
CT scan and liver biopsy confirm cirrhosis
MELD score 23 represents a 35% 90-day mortality rate
INR – 2.2
Bilirubin – 3.7 mg/
dL
Creatinine
serum – 1.4 mg/
dL
Signs and symptoms consistent with diagnosis
Fatigue, weakness, weight loss, bruising, jaundice, abdominal distension, light stools cloudy amber-colored urine, lack of appetite, enlarged
e
sophageal veins, and hepatomegaly.Slide12
Ms. Wilcox’s Weight
Current weight: 125 pounds (56.8 kg)
Height: 5’8” (1.7 m)
BMI = 19
normal
Ideal Body Weight: 140 poundsSlide13
Energy & Protein Needs
Energy Requirements: 35-40 kcal/kg
1,988-2,272
~2,000-2,300 kcal per day
Protein Requirements: 1.6 g/kg
90-91 grams of protein per daySlide14
Factors affecting diet
Impaired nutrient digestion and absorption due to portal hypertension, decreased pancreatic enzyme production and/or secretion, and villus atrophy
Increased energy expenditure because of the vasodilation and expanded blood volumeSlide15
Laboratory Values
Lab Value
Reference Range
Ms.
Wilcox’s Value
Albumin
3.5-5 g/
dL
2.1
g/
dL
Alkaline Phosphatase
30-120
275
Ammonia
9-33
33
ALT
4-36
62
AST
0-35
230
Lactate Dehydrogenase
208-378
658
PT
12.4-14.4
18.5
Protein
6-8
g/
dL
5.4
Hemoglobin
12-15
10.9Slide16
Medications
Medication
Classification
Purpose
Spironolactone
(25 mg)
K-sparing diuretic
Prevents your body from absorbing too much salt while keeping potassium levels from getting too
low; prescribed to help treat edema
Propranolol (40 mg)
Beta-blocker
Decreases blood pressure;
prescribed to help treat portal hypertensionSlide17
Nutrition Diagnosis
PES Statement #1 – Inadequate Protein-Energy Intake
P: Inadequate protein-energy
i
ntake (NI – 5.3)
Related to
E: Inability to consume adequate amounts of food, impaired nutrient absorption and digestion, and increased energy expenditure
As evidenced by
S: 10-pound weight loss in 6 months, lack of appetite, inadequate intake based on client remarks and diet history, and laboratory results.Slide18
Nutrition Diagnosis
PES Statement #2- Unintended Weight Loss
P:
Unintended Weight Loss (NC
–
3.2)
Related to
E:
Decreased appetite, fatigue, and nausea by recent cirrhosis of the liver diagnosis
As evidenced by
S:
Client statements and 10 pound weight loss in past 6 months.Slide19
Nutrition Intervention
Calorie recommendations –
2,000 to 2,300 kcal/day
Protein intake –
90 to 91 g/day
Total calories from fat – No more than 690 kcal
Carbohydrate consumed throughout the day
2 grams Na/day
Mechanically soft diet with small, frequent meals
Discharged with 2-L fluid restriction, but fluids are not usually restrictedSlide20
Nutrition Intervention
Ms. Wilcox asked about using salt-substitutes
Avoid salt substitutes due to high potassium content
Risk of hyperkalemia
Use Mrs. Dash or other spices
Compliance with sodium and fluid restriction
Replace juice in the morning with whole fruit or other solid breakfast item
Drain broth from soup or replace soup with sandwich or salad
Low-sodium soup (<500mg) with unsalted crackers
Reduce Diet Coke consumption
Limit carry-out to 1-2 nights per weekSlide21
One month later
Weight = 140 pounds
Her shoes do not fit on her feet. Why could this be?
Diet Recall:
Total calories: 2,188
FAT: 113.9 g; 1,007 kcal; 46% total kcal
CHO: 193.6 g; 740 kcal; 34% total kcal
PRO: 108.3 g; 444 kcal; 20% total kcal
Sodium: 2,896.6 gSlide22
Resources
Akry
, R. A. (1989). Hypoglycemia associated with liver disease and ethanol [Abstract].
Endocrinol
Metabolic Clinic North America, 18
(1), 75-90.
Fowler, C. (2009). Critical nursing challenge: patients with end-stage liver disease. Retrieved from https://web-
ded.uta.edu
/
wconnect
/ace/static/
onlinecne
/CEMay09.pdf
Hepatorenal
syndrome. (2012).
U.S. National Library of Medicine.
Retrieved from http://
www.ncbi.nlm.nih.gov
/
pubmedhealth
/PMH0001519/#adam_000489.disease.causes
"International Dietetics and Nutritional Terminology (IDNT) Reference Manual: Standard Language for the Nutrition Care Process."
International Dietetics and Nutritional Terminology (IDNT) Reference Manual: Standard Language for the Nutrition Care Process.
Academy of Nutrition and Dietetics,
n.d.
Web. 20 Sept. 2013.
Liver cirrhosis: A toolkit for patients
. (2011). Informally published manuscript, University of Michigan Health System. Retrieved from http://
www.med.umich.edu
/
hepatology
/images/Cirrhosis%20Patient%20Toolkit.v2.
pdfSlide23
Resources
Longstreth
, G. F. (2011). Hepatic encephalopathy.
MedlinePlus
.
Retrieved from http://
www.nlm.nih.gov
/
medlineplus
/
ency
/article/000302.htm
Mayo Clinic (2013).
MELD Score and 90-Day Mortality Rate for Alcoholic Hepatitis.
Retrieved from http://
www.mayoclinic.org
/meld/mayomodel7.html
Nemls
, M.,
Sucher
, K. P., Lacey, K., & Roth, S. L. (2011). Diseases of the Liver, Gallbladder, and Exocrine Pancreas. In Y.
Cossio
(Ed.),
Nutrition Therapy & Pathophysiology
(pp. 437-470). Belmont, CA: Wadsworth.
WebMD. (2013). What is portal hypertension?
Digestive Disorders Health Center.
Retrieved from http://
www.webmd.com
/digestive-disorders/digestive-diseases-portal
Yeung
, E., & Wong, F. S. (2002). The management of cirrhotic ascites.
Medscape General Medicine
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(4), Retrieved from http://
www.medscape.com
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