Michelle Hoffman
Cirrhosis of the Liver Case Study
Mrs. Matuszak
11/13/2012
1. The liver is an extremely complex organ that has a particularly important
role in nutrient metabolism. Identify three functions of the liver for each of
the following:
a. Carbohydrate metabolism:
i. The process of gluconeogenesis, which is the breakdown of
glucose from a non-carbohydrate source, occurs in the liver, and is
often necessary when food has not been consumed in a long time.
Without the ability to do this, our bodies would eventually shut
down. Another function of the liver in terms of carbohydrate
metabolism is glycogenesis, or the synthesis of glycogen from
glucose to use as our primary energy source. The liver is also
responsible for glycolysis, which is the breakdown of glucose by
enzymes, releasing energy and pyruvic acid in the process.
1. Nutrition Therapy & Pathophysiology, pg. 440
2. http://www.vivo.colostate.edu/hbooks/pathphys/digestion/li
ver/metabolic.html
b. Protein metabolism:
i. The liver is necessary for the synthesis of serum proteins (or blood
proteins), which are needed for transportation, enzyme function,
and immune health. It is also needed for the synthesis of
prothrombin, which plays a large role in blood clotting, and finally
providing the globin for hemoglobin. Without globin, our bodies
would be unable to transport oxygen to the blood.
1. Nutrition Therapy & Pathophysiology, pg. 440
2. http://www.vivo.colostate.edu/hbooks/pathphys/digestion/li
ver/metabolic.html
c. Lipid metabolism:
i. Among the several functions related to lipid metabolism, the liver
is responsible for lipogenesis (the formation of fat), lipolysis (the
hydrolysis of triglycerides), and ketogenesis (the production of
ketones from the breakdown of fat for energy).
1. Nutrition Therapy & Pathophysiology, pg. 440
2. Previous knowledge
d. Vitamin and mineral metabolism:
i. The liver is needed for the formation of acetyl CoA from
pantothenic acid, synthesis of bile, the formation of vitamin B12,
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and so on. Acetyl CoA plays a key role in producing energy in the
body, bile is needed for breaking down fat-soluble vitamins, and
the formation of B12 has several functions needed for survival,
such as its role in the synthesis of red blood cells.
1. Nutrition Therapy & Pathophysiology, pg. 440
2. http://www.helpguide.org/harvard/vitamins_and_minerals.
htm
2. The CT scan and liver biopsy confirm the diagnosis of cirrhosis. What is
cirrhosis?
a. The twelfth leading cause of death in the U.S., cirrhosis is a serious
condition that occurs as the end stage of liver disease. In basic terms,
cirrhosis is the replacement of healthy tissue in the liver by scar tissue,
which blocks the flow of blood through the liver and can cause kidney
failure, enlarged liver, thickening of various tissues, portal hypertension,
ascites, and so on. If this condition continues to get worse, patients may
need a liver transplant, and nutrition therapy is recommended due to the
altered metabolism of nutrients and other resulting complications.
1. Nutrition Therapy & Pathophysiology, pgs. 456-457
2. http://www.nlm.nih.gov/medlineplus/cirrhosis.html
3. The most common cause of cirrhosis is alcohol ingestion. What are
additional causes of cirrhosis? What is the cause of this patient’s cirrhosis?
a. There are multiple causes of cirrhosis, the most common from hepatitis C,
alcoholic liver disease, nonalcoholic steatohepatisis, hepatitis B,
cryptogenic causes, cystic fibrosis, Wilson’s disease, autoimmune
hepatitis, and so on. Ms. Wilcox is not a chronic alcohol abuser, and the
cause of her cirrhosis is most likely from her chronic hepatitis C infection
that she was diagnosed with three and a half years ago.
i. Nutrition Therapy & Pathophysiology, pg. 458
4. Explain the physiological changes that occur as a result of cirrhosis.
a. Cirrhosis alters several physiological functions in the body. As
mentioned, the metabolism of carbohydrates, fat, protein, and
vitamins/minerals are altered to the point where malnutrition is a serious
concern. In addition, a patient with cirrhosis may develop edema/ascites,
esophageal varices, have cardiac and vascular changes, hepatic
encephalopathy, and/or hepatorenal syndrome. Ascites is the buildup of
fluid, and will occur particularly in the legs and abdomen, and this may
lead to a bacterial infection or worse. Excessive fluid intake of sodium
intake may worsen this complication. Esophageal varices are enlarged
blood vessels in the esophagus (result of portal hypertension), and if the
pressure is too high, they may burst causing severe bleeding. Hepatic
encephalopathy is the buildup of toxins in the brain because the liver is
unable to remove toxins from the blood, which can be the cause of death
in these patients. Jaundice is another change that may occur because the
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liver is unable to remove to bilirubin from the blood. Finally, hepatorenal
syndrome causes rapid kidney deterioration, and usually fatal.
i. Nutrition Therapy and Pathophysiology, pg. 459
ii. http://digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis/
5. List the signs and symptoms of cirrhosis, and relate each of these to the
physiological changes discussed in question 4.
a. People with cirrhosis often experience weakness, fatigue, loss of appetite,
nausea, vomiting, weight loss, jaundice, abdominal pain and bloating, high
blood pressure (portal hypertension), low blood pressure, itching, bruising
and bleeding, and spider-like blood vessels on the skin. The weakness and
fatigue may be due to a number of things that are all a result of loss of
liver function. The bloating is most likely due to the ascites and edema
due to the fluid buildup in the system, the weight loss/loss of appetite may
be from decreased appetite also related to the loss of liver function and its
from in metabolism, and high blood pressure would be a result of portal
hypertension from the esophageal varices—these varices make it difficult
to swallow as well, thus further contributing to weight loss. Bruising and
bleeding may be a result of the inability of the liver to synthesize protein
clotting factors.
i. Nutrition Therapy and Pathophysiology, pg. 458
ii. http://digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis/
6. After reading this patient’s history and physical, identify her signs and
symptoms that are consistent with the diagnosis.
a. Ms. Wilcox has reported feeling very weak and fatigued, is experiencing
anorexia, jaundice, bruising, losing weight rapidly, and enlarged veins. To
note, her bilirubin levels are extremely high (approximately 3 mg/dL too
high), which explains why she has slight jaundice of the skin. IN addition,
he blood pressure read 102/65 mmHg, revealing that it is lower than usual
and may lead to a diagnosis of hypoglycemia.
7. Hypoglycemia is a symptom that cirrhotic patients may experience. What is
the physiological basis for this? Is this a potential problem? Explain.
a. Hypoglycemia develops in cirrhosis patients rather commonly as a
complication of septic shock. It occurs because the liver is unable to store
enough energy in the form of glycogen. Because the body is not able to
break down carbohydrates for energy quickly, one should eat small
frequent meals rich in complex carbohydrates such as whole grains.
Although unregulated hypotension is dangerous, this is not a huge
problem for cirrhosis patients.
i. http://www.ncbi.nlm.nih.gov/pubmed/7283559
8. What are the current medical treatments for cirrhosis?
Although this is a treatable condition, the damage cannot be fully reversed, yet by
treating the symptoms, one can prevent cirrhosis from getting worse. Since alcohol
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consumption is one of the primary causes, one must abstain from consuming any type of
alcohol for life. Nutrition therapy & supplementation is also recommended to provide
adequate nutrition to maintain nutrition stores without interfering with other clinical
complications. Since another main cause of cirrhosis is hepatitis C, medication is often
prescribed, which must consider the pharmacokinetic alterations of drugs, the
pharmacodynamic alteration of drugs, and the increased susceptibility of patients to
adverse events particularly hepatotoxicity.
a. Finally, a liver transplant is considered for patients with severe cirrhosis
that are at a life-threatening stage.
i. Nutrition Therapy & Pathophysiology, pg. 459
ii. http://digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis_ez/#treatme
nt
9. What is hepatic encephalopathy? Identify the stages of encephalopathy and
outline the major theories regarding the etiology of this condition.
a. Hepatic encephalopathy is caused by disorders that affect the liver, such as
cirrhosis and/or portal hypertension, yet the exact cause is not known. It is
defined as the buildup of toxins in the brain due to the liver being unable
to remove those toxins from the blood and can be short-term or long-term.
Ammonia is one of those “toxins” which may cause damage to the brain,
which is why excessive protein intake is very dangerous for someone who
has HE. This leads to neuropsychiatric abnormalities that cause varying
degrees of personality changes, intellectual impairments, and different
levels of consciousness. Further complications include brain swelling,
permanent nervous system damage, heart failure, coma, and/or death. As
mentioned, HE may range from mild to severe, and the treatment will be
different according to the stage one is at with the condition.
i. http://emedicine.medscape.com/article/186101-overview
ii. http://www.liverfoundation.org/abouttheliver/info/hepaticencephal
opathy/
10. Protein-energy malnutrition is commonly associated with cirrhosis. What
are the potential causes of malnutrition in cirrhosis? Explain each cause.
a. The main causes for malnutrition are decreased intake, decreased
absorption, metabolic alterations, and iatrogenic factors. Decreased intake
is the primary cause of malnutrition, and may come from anorexia, early
satiety (from delayed gastric emptying), ascites, hepatic encephalopathy
(altered mental status), and frequent hospitalization (due to NPO diets).
Decreased absorption is due to an inadequate bile flow (the liver is not
able to secrete enough bile to break down fat and fat-soluble vitamins),
bacterial overgrowth, and pancreatic insufficiency. Metabolic alterations
are generally due the usage of alternative sources for energy—for example
with an increase in gluconeogenesis, protein catabolism, glucose
intolerance, etc. tend to cause “accelerated rate of starvation.” Iatrogenic
factors cause malnutrition related to how cirrhosis is treated, for example
with very restricted diets or medications that have diuretic side effects.
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i. http://www.medicine.virginia.edu/clinical/departments/medicine/di
visions/digestive-health/nutrition-support-team/nutritionarticles/jun03krenitskyarticle.pdf
11. Outline the nutrition therapy for the following stages of cirrhosis with the
rationale for each:
Sodium Potassium Protein Micronutrients
2g
3g
47 g
Multivitamin
may be
recommended
Cirrhosis
1.8 g
2.5 g
41 g
Multivitamin
w/acute
may be
encephalopathy
recommended;
pay particular
attention to
Vitamin D and
K
Cirrhosis w/
1.8 g
2g
38 g
Multivitamin
ascites and
may be
esophageal
recommended;
varices
pay particular
attention to
Vitamin D and
K
Nutrition Therapy & Pathophysiology, pg. 459
Diagnosis
Stable cirrhosis
Fluid
1.5 L
1.2 L
1.2 L
12. Measurements used to assess nutritional status may be affected by the
disease process and not necessarily be reflective of nutritional status. Are
there any components of nutrition assessment that would be affected by
cirrhosis? Explain.
a. A patient’s urine sample, bone density measurements, as well as
prothrombin time may be affected by cirrhosis. Ascites and edema may
influence urine samples as well as the accuracy of bone density
measurements as well. Prothrombin time is a test that measures how long
it takes blood to clot, yet cirrhosis directly affects thrombin generation,
and thus PT is affected.
i. http://www.uptodate.com/contents/coagulation-abnormalities-inpatients-with-liver-disease
ii. http://www.cof.org.cn/pdf/2007/12/Effect%20of%20Ascites%20on
%20Bone%20Density%20Measurement%20in%20Cirrhosis.pdf
13. Dr. Horowitz notes Ms. Wilcox has lost 10 lbs since her last exam. Assess
and interpret Ms. Wilcox’s weight.
a. Ms. Wilcox’s current weight is 125 lbs (56.8 kg), and at 5’9” (1.7 m), her
BMI is 56.8/(1.7)^2= ~18.5 kg/m^2, putting her in the underweight
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category. Since this is a rather rapid weight loss, Ms. Wilcox could be
experiencing anorexia, malnutrition, and/or increased metabolic rate
related to her hepatitis C and cirrhosis. According to her nutrition history,
she has not had an appetite for the past few weeks, and I would
recommend she get nutrition therapy, perhaps with EN integrated with her
regular PO intake.
14. Identify any nutrition problems using the correct diagnostic term.
a. Inadequate energy intake: NI-1.4
b. Inadequate oral intake: NI-2.1
c. Malnutrition: NI-5.2
d. Inadequate protein-energy intake: NI-5.3
e. Underweight: NC-3.1
i. http://www.adancm.com/vault/IDNT%20e3%20NDTermsNCM.pdf
15. Calculate the patient’s energy and protein needs.
a. It is recommended that cirrhosis patients consume 35-40 kcal/kg per day
as well as 1.6 g/kg per day of protein. Ms. Wilcox is 56.8 kg, and 35 x
56.8= 1,988 calories; 40 x 56.8= 2,272 calories, creating a range of 2,0002,200 calories/day. For protein, 1.6 x 56.8=90.8, or ~91 g protein/day.
i. Nutrition Therapy & Pathophysiology, pg. 459.
16. What guidelines did you use and why?
a. I chose to use the general recommendations for cirrhosis as stated in
Nutrition Therapy & Pathophysiology, 2/e. There might be an increased
protein need if her condition worsens or her symptoms become worse.
There might be an increased metabolic rate if she gets sicker as well,
meaning she would need to consume more calories.
17. Evaluate the patient’s usual nutritional intake.
a. Her usual intake has changed recently, as seen by her 10 lb weight loss.
As mentioned she has not had an appetite for the past few weeks. She eats
smaller, frequent meals with small sips of water and soda. Generally, she
will only drink calcium-fortified orange juice for breakfast, soup with
crackers and Diet Coke for lunch, and some sort of carry out for dinner,
however she has not eaten anything in the past 2 days. She clearly does
not consume enough calories nor does she have a balanced diet, lacking in
fruits, vegetables, whole-grains, or fiber. She should become a nutrition
therapy regimen immediately so her health does not falter further.
18. Her appetite and intake have been significantly reduced for the past several
days. Describe the factors that may have contributed to this change in her
ability to eat.
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a. The factors that contribute to her inability to eat are those experienced by
most cirrhosis patients and relate to the signs & symptoms and cause early
satiety, malnutrition, and anorexia. These include abdominal
pain/swelling, altered gut motility, and nausea—these all may lead to
functional dyspepsia, leading to an increased severity of GI symptoms
associated with Ms. Wilcox’s recent weight loss.
19. Why was a soft, 4-g Na, high-kcalorie diet ordered? Should there be any
other modifications?
a. As previously mentioned, cirrhosis of the liver patients have increased
calorie needs for several reasons. Some people experience an increase in
their metabolic rate due to the stress and other factors related to their
sickness. Since most patients experience a lack of appetite, it is more
likely that they will be underweight, and will need more calories in order
to help them gain weight. They have problems with nutrient absorption as
well, meaning they are underutilizing the energy they are consuming in the
first place. Although she is ordered 4-gram Na/day, it is recommended
that cirrhosis patients consume no more than 2 grams per day because
sodium intake will cause the body to retain water, and since they are
already experiencing ascites and edema, excessive fluid buildup could
dangerous.
i. Nutrition Therapy & Pathophysiology, pg. 459
ii. http://www.hepatitis.va.gov/patient/diet/tips-for-people-withcirrhosis.asp
20. This patient takes multiple dietary supplements. Identify the possible
rationale for each and identify any that may pose a risk for someone with
cirrhosis.
a. Ms. Wilcox takes in 400 mg of vitamin E, 600 mg of calcium, and a 400
IU of vitamin D. Vitamins’ E and D are fat-soluble, and the reason she
needs to supplement them is because the liver is compromised and thus
not able to produce sufficient bile salts needed to absorb these nutrients.
Vitamin E is also a known antioxidant, and studies have shown that
antioxidant levels are much lower in cirrhosis patients, which increases
their chance of a cancer diagnosis. Vitamin D and calcium are critical for
bone health, and cirrhosis patients often have decreased bone density (thus
osteoporosis), so supplementation of D and Ca would help slow down the
onset of osteoporosis. There are some herbs and supplements that are
toxic in high amounts, and may harm the liver, and should be used with
caution. These include niacin, vitamin A, beta-carotene, and potassium.
i. http://www.tcolincampbell.org/courses-resources/article/cirrhosissymptoms-and-risk-factors/category/gastrointestinaldisorders/?tx_ttnews%5BbackPid%5D=76&cHash=6508c884dc1
5dba48ed5f3f4ba99d49e
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21. Examine the patient’s chemistry values. Which labs support the diagnosis of
cirrhosis? Explain their connection to the diagnosis.
a. There are several abnormal lab values that support Ms. Wilcox’s cirrhosis
diagnosis. These include her ALT, AST, albumin, and bilirubin levels.
Her ALT and AST are much higher than the normal ranges, which are
indicative of liver damage, specifically bile duct blockage from cirrhosis.
Her albumin levels are lower than what is healthy as well, which also
suggests liver disease and show malnutrition and protein deficiencies.
Finally, her very high bilirubin levels are the most indicative of liver
disease because cirrhosis patients cannot process bilirubin, causing a
buildup—jaundice being a telltale sign.
i. http://labtestsonline.org/understanding/analytes/bilirubin/tab/test
ii. http://labtestsonline.org/understanding/analytes/albumin/tab/test
22. Examine the patient’s hematology values. Which are abnormal, and why?
a. After reviewing Ms. Wilcox’s blood tests, there are several values that are
slightly higher or lower than they should be. Her RBC (red blood cell)
count is 4.1 L, when 4.2-5.4 L is the normal range. This is a common
attribute to cirrhosis patients, and reveals that the patient is in oxidative
stress. Her bilirubin levels were very high, and since the liver should
secrete bile in order to sort blilrubin from the blood cells, an impaired liver
would not be able to. Next, her PT (prothrombin time) is tested in order to
measure how quickly the blood clots, and PT is altered in cirrhosis
patients; Ms. Wilcox’s PT levels were shown to be higher than normal,
showing that the liver was not producing the blood clotting factors a
healthy liver would.
i. http://www.lef.org/protocols/gastrointestinal/cirrhosis_liver_disea
se_01.htm
23. Does she have any physical symptoms consistent with your findings?
a. Yes, Ms. Wilcox reported have yellowish skin, which would be due to her
high bilirubin levels. Her fatigue, nausea, and vomiting symptoms are
also indicative of her abnormal hematology values.
24. What signs and/or symptoms would you monitor to determine further liver
decompensation?
a. Since Ms. Wilcox is already having trouble with her appetite and is losing
weight very quickly, her anorexia is a concern I would monitor closely to
make sure it does not worsen, because without sufficient nutrient intake,
her body will not be able to heal in the most efficient way.
25. Dr. Horowitz prescribes two medications to assist with the patient’s
symptoms. What is the rationale for these medications, and what are the
pertinent nutritional implications for each?
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Medication
Spironolactone
Propanolol
Rationale for Rx
Nutrition Implications
This is a potassium-sparing This may cause an
diuretic, meaning that it
increased loss of sodium in
prevents your body from
the urine, and people taking
absorbing too much salt
this should avoid excess K
while keeping potassium
intake, salt substitutes,
levels from getting too low. natural licorice—may lead
This helps treat edema in
to increased thirst, diarrhea,
cirrhosis patients
and/or gastritis
This drug is a beta-blocker
Taking this drug with
which affects blood flow
calcium, antacids, or high
through arteries and veins
doses of vitamin C may
and decrease blood
decrease its absorption in
pressure; in cirrhosis
the body; there is a possible
patients, this may be taken
chromium deficiency; avoid
to help treat portal
natural licorice
hypertension
http://www.drugs.com/spironolactone.html
Nutrition Therapy & Pathophysiology, pg. 449
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682607.html
26. If the patient’s condition worsens (e.g., acute varices, bleeding, progression to
hepatic encephalopathy), the following medications could used. Describe
each drug classification and mechanism.
Drug
Vasopressin
Classification
Neurohypophysial hormone
Lactulose
Synthetic sugar; GI agent &
Hyperosmotic laxative
Neomycin
Aminoglycoside antibiotic
Mechanism
Regulates urinary H2O loss
and overall H2O balance,
blood pressure via this
hormone’s pressor effects
on blood vessels
(antidiuretic hormone)
Fermented by bacteria in
the colon into short-chain
fatty acids where it acts as a
prebiotic, osmotically active
laxative (to help treat
constipation), and reduce
blood ammonia levels
Prevents/treats skin
infections caused by
bacteria by interfering with
bacterial protein synthesis;
absorbed from the
peritoneum, respiratory
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tract, bladder, wounds and
inflamed skin; little is
absorbed when applied
topically
Essential mineral in the
body used to treat iron
deficiency anemia (lack of
red blood cells)
Stimulant laxative
Works directly on the colon
Bisacodyl
to produce a bowel
movement
Stool softener
Used to treat or prevent
Docusate
constipation or even
hemorrhoids—works to
reduce the pain
Antihistamine
Mainly used to treat allergic
Diphenhydramine
reactions by preventing
histamine from
binding/stimulating cells
Nutrition Therapy & Pathophysiology, pgs. 472,
http://www.drugbank.ca/drugs/DB00581
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682274.html
http://www.drugs.com/ferrous_sulfate.html
http://www.drugs.com/cdi/bisacodyl.html
http://www.medicinenet.com/diphenhydramine/article.htm
Ferrous sulfate
Type of iron
27. What is the recommendation regarding alcohol intake when cirrhosis is
caused by the hepatitis C virus?
a. Cirrhosis is most likely due to alcohol consumption and/or hepatitis C,
thus these patients should not drink alcohol once they have been
diagnosed at all. Drinking alcohol increases liver damage in hepatitis C
patients, making symptoms more severe. Even after 40 years of living
with a hep C infection, moderate drinking will lead to liver scarring; heavy
drinkers would have twice the scarring in only 25 years.
i. http://pubs.niaaa.nih.gov/publications/arh27-3/232-239.htm
28. Select two high-priority nutrition problems and complete the PES statement
for each.
a. Inadequate energy intake related to decreased appetite, fatigue, and nausea
by recent cirrhosis of the liver dx as evidenced and diet recall.
b. Underweight related to decreased appetite in past three weeks as
evidenced by diet recall, recent 10 lb weight loss, and BMI of 18.5
kg/m^2.
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29. Ms. Wilcox is discharged on a soft, 4-g Na diet with a 2-L fluid restriction.
Do you agree with this decision?
a. It is recommended that cirrhosis patients consume no more than 2 g
Na/day because sodium intake will cause the body to retain water, and
since they are already experiencing ascites and edema, excessive fluid
buildup could dangerous. Ms. Wilcox also needs to make sure her 2-L
fluid restriction is met, and to add a little room to ensure she doesn’t
consume too many fluids, recommending ~1.5 L-2 L would be safe.
i. Nutrition Therapy & Pathophysiology, pg. 459
30. Ms. Wilcox asks if she can use a salt substitute at home. What would you tell
her?
a. Since restricting her salt intake is so important, I would recommend a salt
substitute because it will add flavor to foods, hopefully allowing her to
consume the calories she needs to gain healthy weight and absorb enough
nutrients, without adding the fluid-retaining sodium. Ms. Wilcox should
be careful about which substitute to use. She should use one that doesn’t
contain potassium, because blood potassium levels can increase with
certain medications used to treat ascites. Along with using salt substitutes,
she should also use more spices and herbs for flavoring.
i. http://www.liversupport.com/wordpress/2009/08/important-factsabout-salt-and-cirrhosis/
31. What suggestions might you make to assist with compliance for the fluid
restriction?
a. I would recommend that Ms. Wilcox take a diuretic in order to help with
the ascites retaining excessive fluids in her system. In addition,
Abdominal paracentesis should be performed and ascitic fluid should be
obtained from inpatients and outpatients with clinically apparent newonset ascites
32. When you see Ms. Wilcox 1 month later, her weight is now 140 lbs. She is
wearing flip-flops because she says her shoes do not fit. What condition is
she most probably experiencing? How could you confirm this?
a. Her shoes do not fit more likely because her feet are swollen due to
edema, or fluid retention from her liver damage. This is a common
symptom of portal hypertension and is often accompanied by ascites of the
abdomen. The doctor should therefore see if her abdomen is abnormally
bulging as well. Another clue that this is ascites is that she has gained 15
lbs in 4 weeks. Although it is good that she is reaching a healthy weight,
it may be due to fluid retention, or “water weight.” A 24-hr urine
collection should be ordered in order to measure how much sodium she is
excreting, and it it’s adequate.
33. Her diet history is as follows:
a. Breakfast: 1 slice toast with 2 tbsp peanut butter, 1 c skim milk
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Lunch: 2 oz potato chips, grilled cheese sandwich, (1 oz. American cheese
with 2 slices of whole-wheat bread; grilled with 1 tbsp margarine), 1 c
skim milk
Supper: 8 barbeque chicken wings, french fries—2 c, 2 c lemonade
b. What changes might you make to her nutrition therapy? Identify
foods that should be eliminated and make suggestions for
substitutions.
c. I think her breakfast is appropriate because it has adequate protein,
calories, and fluid while very low in sodium. However, I would include a
fruit that doesn’t have a high water level. Her lunch is generally healthy
as well; I may include some green vegetables, such as steamed broccoli.
Her dinner is higher in sodium than I’d like to see, I would make sure the
fries are baked with a sodium-substitute and/or spices. Instead of BBQ
wings, I would choose a lean chicken with no added salt or a grilled fish.
Her fat consumption should not exceed 30%, and including more MUFA’s
and PUFA’s would be beneficial. Another concern I have is how her diet
is distributed throughout the day. She is consuming 3 large meals per day,
yet I would recommend spacing out these meals into small, frequent
feedings. To ensure she is absorbing all the nutrients she is consuming, a
multivitamin may be issued—Ms. Wilcox should check with her doctor
before use due to possible drug-nutrient interactions.
34. Over the next 6 months, Terri’s cirrhosis worsens. She is evaluated and
found to be a good candidate for a liver transplant. She is placed on a
transplant list and, 20 weeks later, she receives a transplant. After the liver
transplant, what diet and nutritional recommendations will the patient need
before discharge? For the long term?
Kcal
Protein
Fat
CHO
Sodium
Fluid
Calcium
Vitamins
Immediate Posttransplant
(First 2 months)
15-30% above basal needs
Long-Term
Posttransplant
Maintain; partially
dependent on physical
activity level
1.5-2 g/kg/day
Dependent on physical
activity level
30% of calories/day
No more than 30% of
calories/day
50-60% of calories/day
Maintain; partially
dependent on physical
activity level
No more than 2-g/day
No more than 2-g/day
1.2-1.5 L/day
~1.2 L/day
~1,000 mg/day
~1,500 mg/day
May need multivitamin
May need multivitamin
supplement; see doctor
supplement; see doctor
Nutrition Therapy & Pathophysiology, pg’s. 459-460
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