Professional Documents
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FSHN 450
Fall 2015
Due Date: November 6, 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 (yellowing of the eye), increased abdominal girth
secondary to ascites, black stools.(due to bleeding from ulcer or from esophageal)
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
Patients values
120 mEq/L
Normal ranges
136-144
K
Cl
4.7 mEq/L
87 mEq/L
3.5-5
98-107
CO2
Glu
BUN
Creat
19.3 mmol/L
91 mg/dl
13 mg/dl
1.6 mg/dl
22-29 mmol/L
70-99 mg/dl
8-23 mg/dl
0.4-1.2
PTT
43.1 sec
23-36 sec
RBC
Hgb
4.7-6.1 million/mm3
14.6-17.5 g/dl
Hct
26.9%
41-51%
Albumin
2.3 g/dl
3.5-5.0 g/dl
Triglycerides
325 mg/dl
<150 mg/dl
Total cholesterol
250 mg/dl
120-199 mg/dl
HDL-cholesterol
40 mg/dl
40-60 mg/dl
Reasoning
Low due to
malabsorption
normal
Low due to acute
infection, edema
Metabolic acidosis
normal
normal
Increased due to renal
disease
High due to hepatic
disease
low
Low due to cirrhosis,
anemia
Low due to cirrhosis,
anemia
Low due to hepatic
disease, anemia
Alcoholism, hepatic
disease
High due to alcohol
intake
normal
What is the purpose of each of the patients medications? List any important
drug:nutrient interactions.
TUMS- Used to help with patients GERD because antacids help with acid reflex. Patient should
be taking this antacid with adequate vitamin D essential to normalize Ca/ bone metabolism
Zantac- An antigerd, a balanced diet is recommended. Take drug at least 2 hr before or after Fe
suppl. Take Mg suppl or Al/Mg antacids separately by at least 2 hrs. limit caffeine.
Lisinopril- is used as antihypertensive drug which may decrease weight.
Lactulose- to treat increased ammonia levels. No not take concurrently with antacid. Increase
fiber and drink lots of fluids
Octreotide- used for treating bleeding esophageal varices. Monitor fat-soluble vitamin absorption
Vitamin K- given because intestinal disease may decrease absorption of vit K, which is why you
give a Vit K supplement. There is no known toxicity
Compazine- has anticholinergic effects and hypotension but less ESP. This drug can increase
appetite, weight and could decrease absorption of B12
Morphine- is used to help with patients pain. Take with food to decrease GI distress. This drug
can cause of decrease in weight and increase thirst.
albumin iv- pt albumin levels are low so he needs to be supplemented with an albumin iv which
can also help the pt diuretic be more responsive. Do not mix with protein hydrolysates or
solutions containing alcohol.
furosamide iv- is used to with hepatic cirrhosis and edema associated with that. It inhibits Na and
Cl from being reabsorbed in the loop of the renal, monitor pt electrolyte levels
Evaluate the patients 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.
I would prescribe a disease specific enteral feeding called Nutrihep. This product is caloric dense
for fluid management and nutrient absorption.
Patient kcal needs
25 kcal/kg BW/day so 25 kcals*87.9kg = 2,197.5 kcals/kg/day.
Na
Patients values
122 mEq/L
Normal ranges
136-144
K
Cl
4.1 mEq/L
98 mEq/L
3.5-5
98-107
CO2
10 mmol/L
22-29 mmol/L
Glu
BUN
Creat
93 mg/dl
18 mg/dl
1.6 mg/dl
70-99 mg/dl
8-23 mg/dl
0.4-1.2
PTT
43.1 sec
23-36 sec
RBC
Hgb
4.7-6.1 million/mm3
14.6-17.5 g/dl
Hct
26.9%
41-51%
Albumin
2.6 g/dl
3.5-5.0 g/dl
Reasoning
Low due to
malabsorption
normal
Low due to acute
infection
Decreased due to
acidosis
normal
normal
Increased due to renal
disease
High due to hepatic
disease
low
Low due to cirrhosis,
anemia
Low due to cirrhosis,
anemia
Low due to hepatic
disease, anemia
List the probably reasons for the tube feeding intolerance in this patient?
Pt conditions are worsening due to his GI bleeding enabling the tube feeding to be affective.
Since the pt is experiencing GI bleeding he is under a lot of distress and also can not absorb
nutrients needed through his intestines.
You do not need to calculate a TPN but you should reevaluate protein and Kcal needs.
I would keep kcal where they are at, so 30kcals/kg Wt/day which would equal 2,637 kcal/day.
But because pt is now on Hepatamine and is high in PRO, I would decrease PRO to .8g PRO/kg
Wt/day, so .8*87.9 = 70.32g PRO/kg/day
Why was Hepatamine ordered and what at is the drawback to using this product?
Hepatamine was order because Hepatamine is used to treat pts with cirrhosis who are not
receiving enough PRO due to intolerant of general purpose of amino acids. Hepatamin contains
both essential and non-essential amino acids which can help decrease blood ammonia levels. The
drawback of using Hepatamine is that it interacts with a lot of drugs; it can also increase BUN
levels, increase fluid retention, decrease blood sodium, and cause fever.
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.
Poor nutrition quality of life R/T alcoholism AEB dx of chronic alcoholic cirrhosis with
stable encephalopathy and esophageal varice.
o Intervention:
encourage a diet high protein to normalize serum AA
educate pt on drug nutrient interaction
educate pt on alcoholism and his diagnosis so he understands the severity
if he continues to drink
o Monitor/Evaluate:
At follow up appointment reevaluate pt conditions and see if they have
gotten worse or better.
At follow up appointment see if pt has stopped using alcohol and if not see
if he needs further guidance for quitting.