Rachel Hart
KNH 411
11/27/2012
Acute Hepatitis CS
I. Understanding the Disease and Pathophysiology
1. Several specific versus that cause hepatitis have been identified. Describe the
following characteristics of each.
Characteristic
Likely mode
of
transmission
Hepatitis A
HAV
Oral-fecal
route
Symptoms
Dark urine,
fatigue,
itching, loss of
appetite, lowgrade fever,
nausea and
vomiting, pale
or clay colored
stool, jaundice
Population
most often
affected
More likely in
adults who
travel
internationally,
use IV drugs,
live in a
nursing home,
work in the
health care
setting
Means of
reducing
exposure
Receiving the
HAV
vaccination
Treatment
No special
treatment, rest,
adequate
nutrition and
fluids are
Hepatitis B
HBV
Transfusions of
blood or bloodderived fluids
or instruments
that have come
into contact
with blood
There may be
no symptoms,
some may feel
sick for a
period of days
or weeks, and
some may be
very ill
Hepatitis C
HCV
Sharing
needles, having
unprotected
sexual contact
with a person
who has the
disease
Abdominal
pain or
swelling, pale
or clay colored
stool, dark
urine, fatigue,
fever, itching,
jaundice, loss
of appetite,
nausea,
vomiting
Those on longtern kidney
dialysis, health
care workers,
those having
unprotected
sex, drug
addicts, those
who have
visited
unrepeatable
tattoo parlors
Those who are
infected with
HIV, being on
hemodialysis,
having
multiple sexual
partners,
having sexual
intercourse
with men,
having a parent
who has the
disease
Sterilizing
instruments
used, receiving
the HBV
vaccination
Acute hepatitis
needs no
treatment other
than careful
monitoring of
1
Hepatitis D
HDV
Only found in
people who
carry the HBV
Hepatitis E
HEV
Contaminated
drinking water
Abdominal
pain, dark
colored urine,
fatigue,
jaundice, joint
pain, loss of
appetite,
nausea,
vomiting
Jaundice,
anorexia,
enlarged or
tender liver,
abdominal
pain, nausea,
vomiting, fever
Drug addicts,
babies who are
carried in a
mother with
the virus,
anyone with
HBV, having
sexual
intercourse
with men,
receiving blood
transfusions
Those who
practice poor
sanitation in
large areas of
the world and
shedding of the
hepatitis E
virus in feces
Not sharing
needles and
practicing safe
sex
Sterilizing
instruments
used, receiving
the HBV
vaccination
To remove the
virus from the
blood and
reduce the risk
of cirrhosis and
Medication
Prevention is
the most
effective
approach
against the
disease
There is no
available
treatment
capable of
altering the
recommended
liver and other
body functions
with blood
tests. You
should get
plenty of bed
rest, drink
plenty of
fluids, and eat
healthy foods
liver cancer
that can result
from long-term
HCV infection,
can treat with
medication
course of acute
hepatitis
(Nelms et al., 2011, p. 447-450)
2. Describe hepatitis C to Ms. Wilcox as you would a patient.
Hepatitis is the inflammation of the liver that can come from many sources such
as toxins, certain drugs, some diseases, heavy alcohol use, and bacterial and viral
infection. Specifically, you have been diagnosed with hepatitis C, which is a
contagious liver disease that ranges in severity from a mild illness lasting a few
weeks, to a serious, lifelong illness that attacks the liver. It results from infection
with the Hepatitis C virus (HCV), which is spread primarily through contact with
the blood of an infected person, although it can also spread through sex with an
infected person and from mother to baby during childbirth (National Institutes of
Health [NIH], 2012). Hepatitis C can be either acute or chronic, depending on if
the virus remains in the body. Acute Hepatitis C virus infection is a short-term
illness that occurs within the first 6 months after someone is exposed to the
Hepatitis C virus. For most people, acute infection leads to chronic infection.
Chronic Hepatitis C is a serious disease than can result in long-term health
problems and should be treated as soon as possible (Center For Disease Control
and Prevention [CDC], 2012).
3. What signs and symptoms does Ms. Wilcox have?
Ms. Wilcox is experiencing fatigue, muscle and joint aches, malaise, vague upper
right quadrant pain, nausea, weight loss, and anorexia. Ms. Wilcox is also
experiencing upper right abdominal guarding and elevated liver enzymes (Nelms
et al., 2009, p. 183-194).
4. Are there any other typical signs and symptoms of hepatitis that Ms. Wilcox
does not have?
Many people infected with HCV do not have any symptoms. However, when
symptoms are present, they range from mild to severe. Some symptoms that Ms.
Wilcox is not experiencing are dark urine, headache, fever, clay-colored bowel
movements, and jaundice (CDC, 2012).
5. Describe how the symptoms of hepatitis are related to the pathophysiology of
the disease.
The liver is integral to most metabolic functions of the body and performs more
than 500 tasks, including carbohydrate, protein, and fat metabolism, storage and
activation of vitamins and minerals, and action as a filter. It is no wonder that
when the liver is malfunctioning or is in a disease state, that many symptoms
2
arise. Symptoms occur because of the reduced functions of the liver when
hepatitis or any disease state is present (Nelms et al., 2011, p. 447-450).
6. Teresa Wilcox is devastated by the diagnosis. She tells Dr. Horowitz that
she’s never had a blood transfusion or been exposed to blood products. She
has never used IV drugs, but did inhale cocaine once or twice at parties in
college. She has had several sexual partners, and the only time she has come
into contact with any kind of needles was when she had her naval pierced six
months ago. How, most likely, did Terri contract hepatitis C?
Ms. Wilcox most likely contracted hepatitis C six months ago, while getting her
naval pierced. Hepatitis C is usually spread when blood from a person infected
with the hepatitis C virus enters the body of someone who is not infected. Today,
most people become infected with the hepatitis C virus by sharing needles or
other equipment to inject drugs (CDC, 2012). The place of business where Terri
had her naval pierced could have not properly cleaned her piercing utensils or
could have reused the same needle on Terri as someone with hepatitis C.
II. Nutrition Assessment
7. Calculate the patient’s percent UBW and BMI, and explain the nutritional
risk associated with each value.
No usual body weight was provided so the Hamwi formula was used.
Hamwi= 100 lbs + (5 x 9)= 145 lbs= UBW
% UBW= 130 lbs/145 lbs= .90 x 100%= 90%
% change= 100- 90%= 10%
Ten percent is a significant amount of weight to lose. More information would be
needed to determine the true severity of the situation since the case study does not
offer a time frame for the weight loss (Nelms et al., 2011, p. 47-48).
BMI=[weight(kg)]/[height(m2)]
 Weight= 130/2.2= 59.0 kg
 Height= ((69x2.54)/100)2= 3.07 m2
 BMI= 59.0 kg/ 3.07 m2= 19.2 kg/m2
This BMI is considered within the normal range. If Terri continues to lose more
weight and her BMI decreases to less than 18.5 kg/m2, then she could be placed in
the underweight category and at risk for many health complications including
chronic obstructive pulmonary disease, cancer, and congestive heart failure
(Nelms et al., 2011, p. 48).
8. Because resting energy expenditure varies with liver disease, indirect
calorimetry is recommended. However, you do not have access to this means
of measurement. How would you estimate Ms. Wilcox’s energy and protein
requirements?
3
Typically indirect calorimetry is the gold standard to calculate energy
expenditure. Because this form of estimate is not widely available, energy
estimate equations are often applied in the hospital setting. I would estimate
Terri’s energy requirements using the Mifflin-St. Jeor equation. This equation is
the most recent edition and has been validated in over 10 different studies in the
last decade (Nelms et al., 2011, p. 59). To estimate Ms. Wilcox’s protein
requirements, a range of 1.0-1.5 grams of protein per kilogram of body weight per
day should be used for those in metabolic stress, trauma, or disease (Nelms et al.,
2011, p. 61).
9. Identify any potential nutrition problems regarding micronutrient
requirements. Provide the rationale for why theses micronutrients are of
concern.
Since the liver plays a vital part in nutrition and the digestive systems, those with
hepatitis C should consume adequate micronutrients. Iron, copper, some vitamin
B vitamins, vitamin C, and the fat-soluble vitamins A, D, E, and K are all stored
in the liver. If the liver is not functioning correctly, then the role of these
micronutrients may be severely compromised. Fat-soluble vitamins may not be
converted into the active forms needed in the body and red blood cells may be
negatively affected of iron, copper, and vitamin B12 are not properly used. This
may cause many deficiency symptoms and severe complications (Dietitians of
Canada, 2012).
10. Calculate this patient’s total energy and protein needs using the Mifflin-St.
Jeor equation.
The Mifflin-St. Jeor equation can be used to estimate Terri’s daily energy needs
(Nelms et al., 2011, p. 60).
Mifflin-St. Jeor= 10 x (kg) + 6.25 x (cm) – 5 x (age) – 161
 10 x (65.9) + 6.25 x (175.3) – 5 x (22) – 161= 1,483 kilocalories= REE
 Activity factor= 1.5 for the average adult female who is not sedentary
 TEE= 1.5 x 1,483= 2,225 kilocalories per day or a range of 2,200-2,300
Protein needs: 1.0-1.2 grams of protein for every kilogram of body weight=
65.9- 79.1 grams of protein
11. Using the patient’s usual dietary intake, help her plan a menu.
Usual Diet
Suggested Substitution
Kilocalories
Protein (grams)
1½ cup Sugar Frosted
Flakes
318
8.6
½ cup 2% milk
1½ cup high fiber
oatmeal (no sugar
added or low sugar)
1 cup 1% or skim milk
83
8.3
1 banana
No change
27
1.3
1 cup calcium fortified
orange juice
½ cup calcium fortified
orange juice
57
0.8
4
Iced tea
Water
0
0
Cheeseburger
Grilled chicken
sandwich on 100%
whole wheat bun,
mustard, and veggies
Water
419
32.4
0
0
176
3.0
3 ounces shrimp
Baked sweet potato
wedges
3 ounces shrimp
122
23.5
1½ cup vegetables
No change
45
3.7
1 cup steamed rice
1 cup steamed brown
rice
1 cup 1% or skim milk
684
14.7
83
8.3
1 cup sliced
watermelon
46
0.9
2,138 kilocalories
105.6 grams
12 ounces Diet Coke
French fries
Water
4 cookies
Total:
*All food must be thoroughly cooked to proper internal temperatures and handlers
must make sure to wash their hands to minimize germs.
(FitDay.com, 2011)
12. Identify nutrition problems within the nutritional domain using the correct
diagnostic term.
Nutrition problems include:
Inadequate oral intake (NI-2.1)
Inadequate fluid intake (NI-3.1)
Inadequate protein-energy intake (NI-5.3)
(IDNT, 2011)
13. Examine the patient’s chemistry report. What values would steer Dr.
Horowitz towards the patient’s diagnosis?
Terri’s chemistry panel reveals that there are several lab values that are abnormal.
Her ALT, AST, bilirubin, alkaline phosphatase, and LDH values are all high. In
addition, the hematology panel reveals a high PT and WBC, and a low HGB,
HCT, and platelet count. Lastly, the urinalysis reveals protein in Terri’s urine.
All of these values would point Dr. Horowitz towards the patient’s diagnosis of
hepatitis C (Lab Tests Online, 2012).
14. What do the values measure, and what is their relationship to liver disease?
Lab Value
ALT (high)
AST (high)
Bilirubin (high)
What It Measures
Measures and detects liver
damage
Measures and detects liver
damage
To screen for or monitor liver
5
Relationship To Liver Disease
All types of liver disease can
cause
All types of liver disease can
cause
Cirrhosis, alcoholic liver disease,
Alkaline phosphatase (high)
LDH (high)
PT (high)
WBC (high)
HGB (low)
HCT (low)
Platelet count (low)
Protein in urine (1+)
disorders or hemolytic anemia
To screen for or monitor
treatment for a liver or bone
disorder
Measures tissue damage
Measures how fast the blood clots
Measures the number of white
blood cells in the blood
Measures the hemoglobin content
of the blood
Measures the portion of blood
that is red blood cells
Measures the number of platelets
in the blood
The amount of protein that spills
over into the urine
or viral hepatitis can cause
Liver disease or liver cancer can
cause
Liver tissue damage can cause
Inflammation from liver disease
can cause
Inflammation from liver disease
can cause
Inflammation from liver disease
can cause
Inflammation from liver disease
can cause
Viral infections such as hepatitis
C can cause
Inflammation from liver disease
can cause
(Lab Tests Online, 2012)
15. The results of the anti-HCV and HCV RNA tests that Dr. Horowitz ordered
were positive. What does this mean?
A positive anti-HCV test detects the presence of antibodies to the hepatitis C
virus, indicating exposure to HCV. A positive HCV RNA test detects and
measures the number of viral RNA particles in the blood (Lab Tests Online,
2012). Both of these tests are used to indicate exposure to the HCV and can be
used to diagnose it in patients.
16. Once the diagnosis of hepatitis C is made, the physician orders 3-MU
interferon alfa-2b sq qd, and Rebetol 200 milligrams po bid. What are these
medications, and what do they do?
3-MU interferon alfa-2b used to prevent tumor cells or viruses from growing
inside the body (NIH, 2102). It can be used in combination with other
medications. This medication is taken in a subcutaneous injection, once daily.
Rebetol is a brand name of Ribavirin and is used to treat hepatitis C. It works by
stopping the virus that causes hepatitis C from spreading inside the body. It will
not be affective unless taken with another medication, such as an interferon, and
that is why Dr. Horowitz prescribed it in combination with the 3-MU interferon
alfa-2b (NIH, 2012). This medication is taken in 200-milligram doses by mouth,
twice daily.
17. What are nutritional side effects of interferon and ribavirin?
Most people taking interferon and ribavirin have side effects from the drugs. The
most common include fatigue, fever, muscle aches, headaches, anxiety, skin rash,
depression, nausea, diarrhea, and anorexia. Specifically, nutritional side effects
include, nausea, diarrhea, and anorexia. Monitoring of severe symptoms and
management of all symptoms of side effects is critical to the effective completion
of the therapy that the drugs provide (Department of Veteran Affairs, 2012).
6
18. Given these side effects, what can the dietetic professional do to help the
patient maintain positive nutritional status?
To help the patient maintain a positive nutritional status, the dietetic professional
can instruct the client on how to consume their meals. For nausea, the patient can
take their medication with meals or eat smaller, more frequent meals. In addition,
consuming ginger can help and can be found in ale, tea, and ginger snap cookies.
The patient should also avoid smells and foods that trigger nausea. For anorexia,
eating smaller, more frequent meals may be helpful. Nutritional supplements like
Ensure and nutrient bars and snacks with protein can pack calories in little space.
Lastly, for diarrhea, an oral anti-diarrheal agent can be administered as long as
symptoms exist. Also, caffeine and lactose containing beverages and high-sugar
soft drinks should be avoided. Boiled rice, apples or applesauce, bananas,
oatmeal, and bulking agents such as Metamucil can help solidify stool
(Department of Veteran Affairs, 2012).
19. List nutrition problems with in the clinical domain using the correct
diagnostic term.
Nutrition problems include:
Food-medication interaction (NC-2.3)
Altered nutrition-related laboratory values (NC-2.2)
Impaired nutrient utilization (NC-2.1)
(IDNT, 2011)
20. Ms. Wilcox tells you that a friend suggested she use milk thistle to help fight
the hepatitis virus. What would you tell her?
Although this CAM is generally well tolerated, Terri does not know if she is
allergic to milk thistle. Because she has an allergy to penicillin, I would caution
Terri with its use because people with one allergy are more likely to have another
allergy. In addition, more research is needed to prove the actual effectiveness of
this CAM and its claims to benefit the liver (NIH, 2012).
21. List any potential problems with the behavioral-environmental domain.
Nutrition problems include:
Food and nutrition related knowledge deficit (NB-1.1)
Not ready for diet or lifestyle change (NB-1.3)
Limited adherence to nutrition-related recommendations (NB-1.6)
(IDNT, 2011)
III. Nutrition Diagnosis
22. Select two high-priority nutrition problems and complete the PES statement
for each.
1. Inadequate oral intake related to nausea and anorexia as evidence by 24-hour
recall and weight history.
2. Impaired nutrient utilization related to hepatitis C diagnosis as evidence by
altered chemistry, hematology, and urinalysis lab values.
7
(IDNT, 2011)
IV. Nutrition Intervention
23. As you assess Teresa Wilcox’s nutritional status, what are your concerns?
I am concerned that Terri will have trouble taking in adequate calories, nutrients,
and fluids due to the pain, nausea, and anorexia she is experiencing. These
symptoms can make it very hard for the patient to find motivation to eat and stay
hydrated. Terri’s 24-hour recall revealed that she had not consumed much and I
worry that this will only continue while her symptoms last. If this occurs, then
Terri’s illness will worsen and she will continue to lose weight. Both of these
things are highly undesirable when trying to treat a serious virus. In addition, I
worry that Terri’s hectic lifestyle will interfere with her ability to make significant
changes in her eating patterns.
24. Dr. Horowitz requested your consultation to order the patient’s diet. What
do you recommend?
I recommend a diet that will spare the liver and provide it with the nutrients that
are needed for regeneration, maintenance, and healing. Terri needs adequate
fluids, good nutrition, and avoidance of alcohol to combat her diagnosis (Nelms et
al., 2011, p. 450-451). I would encourage Terri to consume a diet adequate in
energy, protein, and micronutrients. Terri should be on a regular meal schedule,
with her meals spread out into six small feeds a day, to help with her symptoms of
nausea, diarrhea, and anorexia. Terri should consume about 2,100-2,200
kilocalories and 60-90 grams of protein daily. Alcohol should be avoided for the
time being.
25. How will you be able to determine whether this diet prescription is
appropriate?
Through thorough monitoring and evaluation I will be able to determine if the diet
prescription written for Terri is appropriate. First, subsequent visits from Terri
will use her baseline lab values to monitor changes in her chemistry, hematology,
and urinalysis panels. In addition, her anthropometric, BMI, and weight status
data will be monitored in a similar way. If Terri is losing weight, then more
calories and nutrients will be added. If she is gaining weight, then the opposite
action will be taken. These pieces of data will give an accurate picture of how the
diet prescription is working for Terri.
26. For each of the PES statements that you have written, establish an ideal goal
(based on the signs and symptoms) and an appropriate intervention (based
on the etiology).
1. Goal: To eat a balanced diet with adequate calories, protein, and
micronutrients daily. Some intervention strategies would be to eat smaller,
more frequent meals, avoid foods or smells that trigger nausea, and avoid
caffeine, lactose, and high sugar containing beverages.
8
2. Goal: To improve altered chemistry, hematology, and urinalysis lab values
with adequate nutrition. An intervention strategy would be to give basic
nutrition education to show Terri which micronutrients she should be
increasing in her diet and supplementing with outside sources.
9
References
Hepatitis C. (2102). Lab Tests Online. Retrieved from http://labtestsonline.org/
understanding/analytes/hepatitis-c/tab/test
Hepatitis C. (2102). National Institutes of Health [NIH]. Retrieved from
http://www.nlm.nih.gov/medlineplus/hepatitisc.html
Hepatitis C information for the public. (2012). Center For Disease Control and
Prevention. Retrieved from http://www.cdc.gov/hepatitis/c/index.htm
Hepatitis C: Nutrition care. (2012). Dietitians of Canada. Retrieved from http://www.
bccdc.ca/NR/rdonlyres/EA6145BC-FF7B-448A-B5E6-6EDED47D878C/0/Hep_
Guidelines_HCVNutritionCare.pdf
Interferon and ribavirin treatment side effects. (2012). Department of Veteran Affairs.
Retrieved from http://www.hepatitis.va.gov/provider/reviews/treatment-sideeffects.asp
International dietetics & nutrition terminology (IDNT) reference manual: Standardized
language for the nutrition care process, Edition 3. (2011). Academy of Nutrition
and Dietetics. Retrieved from http://www.eatright.org/Health Professionals/
content.aspx?id=5903#.UEo8MXbDaeY
My fitness log: Foods. (2011). FitDay. Retrieved from http://www.fitday.com/
Nelms, M. N., Long, S., Lacey, K. (2009). Medical nutrition therapy: A case study
approach. Belmont, CA: Wadsworth.
Nelms, M., Sucher, K. P., Lacey, K., Roth, S. L. (2011). Nutrition therapy &
pathophysiology. Belmont, CA: Wadsworth.
10
Download

File - Medical Nutrition Therapy Portfolio