Your Name and/or Name of Partner (if working with one):

.ay&or ,asand

University of Minnesota - Department of ood !"ien"e # Nutrition FScN 4665 - Medical Nutrition Therapy I - Fall 2013 Case 3 - e!ised $%% Points "ue "ate# Tuesday$ No!e%&er 1' (ne) due date* P&ease 'e sure to do the fo&&owing: !how a&& "a&"u&ations( and e)p&ain your rationa&e* +a&"u&ations do not have to 'e typed* ,nswer a&& -uestions dire"t&y on this form* .ype a&& answers (e)"ept "a&"u&ations)* !u'mit in hard "opy in "&ass on the due date* You wi&& 'e dedu"ted one point per day after the due date unti& the hard "opy is turned in* You may work ,/0N1 or with 0N1 other person* Do not share your work with other individua&s 'eyond your group* 2f you work with a partner( you shou&d hand in on&y 0N1 "ase with your name and your partner3s name "&ear&y &isted at the top of the first page* !ome resour"es needed for so&ving the +ase: $* /e"ture notes and materia&s posted under the "&ass topi" 45epati" Disorders6 in Mood&e site 7* /e"ture notes on Nutrition ,ssessment 2-5istory and Physi"a& 1)amination 8* /e"ture notes on Nutrition ,ssessment 22- ,nthropometry 9* /e"ture notes on Nutrition ,ssessment 222-:io"hemi"a&//a'oratory ;* Modu&e 2: Nutrition +are Pro"ess( Nutrition Diagnosis and Medi"a& <e"ord Do"umentation =* Modu&e 22: 1nergy( Protein( and &uid <e-uirements in the +&ini"a& !etting >* Modu&e 222: ,n 2ntrodu"tion to the 1)"hange /ists for Mea& P&anning ?* 2DN. Manua& @* Arause3s ood and the Nutrition +are Pro"ess( $8th edition +lcoholic Cirrhosis (1)"erpted from :i&&on( B* +ase 88 ,&"oho&i" +irrhosis( in Clinical Nutrition Case Studies, 3rd edition( Best/Badsworth( :e&mont( +,* $@@@C pp* 7>$ D 7>?*) +,, -.I+TI/NS# Anow&edge of the fo&&owing a''reviations is re-uired in order to understand this "ase*

,/.: ,!.: :<:: D.s: D;B: D): FF.: 2*G*: N/F: N58: NP0:

,&anine aminotransferase ,spartate aminotransferase :right red '&ood De&irium tremens ;E de)trose in water Diagnosis Fammag&utamy& transferase (or transpeptidase) 2ntravenous Nasogastri" ,mmonia Nothing 'y mouth (ni& per os)

0atient 12# Mr* N is a 9;-year-o&d automo'i&e me"hani"* 5e is divor"ed with two "hi&dren who are in "o&&ege* 5e has &ong suffered from depression( and has a &ong-standing history of a&"oho& a'use* ,'out a year ago( he had 'een admitted to the hospita& for treatment of a"ute pan"reatitis and an en&arged fatty &iver* 5e had 'een to&d to fo&&ow a &ow-fat( high protein diet with a'so&ute&y no a&"oho&* 5e improved for a whi&e( 'ut then went 'a"k to drinking* ,ppro)imate&y = months ago( he was admitted to the hospita& with a diagnosis of /aenne"3s "irrhosis with pan"reatitis* ,t that time( he was again dis"harged with the dire"tion to fo&&ow a &ow-fat( high protein( &ow sodium diet( and to "omp&ete&y a'stain from a&"oho&* 0ver the past "oup&e of months he has e)perien"ed a gradua& de"&ine* Mr* N3s "ondition has worsened signifi"ant&y over the past week* 5e is admitted to the hospita& with as"ites and peda& edema* 5is urinary output has 'een de"reasing( and he has not 'een fo&&owing his diet at a&&* 0hysical -2a%ination3+nthropo%etric "ata# Fenera& appearan"e: .ired-&ooking ma&e 5eight: ;3 $$6 ,dmission Beight: $;% &'s Beight today: $;; &'s Beight 7 weeks ago (prior to the deve&opment of as"ites and periphera& edema): $9% &'s Beight = months ago (Usua& :ody Beight): $>% &'s ,s"ites and $H peda& edema 1)hi'its &oss of mus"&e mass (tempora&( interosseous) and su'"utaneous fat (tri"eps( or'ita&) Measured <11 (today): $>7% k"a&s/d Nutrition 12# General: Poor appetite for the past few weeks* 5e has 'een eating very &itt&e( and has not 'een re"eiving the nutrients he needs* 5e has "ontinued to &ose weight* 5e drinks &itt&e water( and reports "onsuming a'out 7% f& oI of vodka every day* 24-hour recall: :reakfast: $= oI "offee ('&a"k)( $ .'sp ha&f and ha&f( $ tsp sugar( 7 s&i"es white 'read( 7 .'sp 'utter (sti"k)

/un"h: Spaghetti with meat sauce: $ " "ooked spaghetti nood&es( J " spaghetti sau"e( $ oI "ooked ground 'eef( $7 f& oI Godka Dinner: +hi"ken sandwi"h( ? f& oI Godka 1ospital course# ,fter a few days without a&"oho&( Mr* N 'egan to have D.s and had to 'e restrained* During this time( he 'egan to ha&&u"inate and use very a'usive &anguage* 5e a&so started to e)hi'it asteri)is* :&ood N58 was drawn and was 9% units//* 5is food and f&uid intake dropped to a&most nothing* 5e was re"eiving D;B 'y 2*G* with added vitamins( minera&s( and e&e"tro&ytes* .hat night he started throwing up &arge amounts of :<:* , !engstaken:&akemore tu'e had to 'e p&a"ed* Mr* N '&ed so e)"essive&y that who&e '&ood had to 'e administered* 5is physi"ian added to his D) the fo&&owing: $* 5epati" en"epha&opathy 7* Porta& hypertension 8* 1sophagea& vari"es Mr* N was now in a semi-"omatose state and had to keep the !engstaken-:&akemore tu'e in p&a"e for another day* ,fter the tu'e was removed( Mr* N had a N/F tu'e in p&a"e to &ow intermittent su"tion* 5e was NP0 and "ontinued to re"eive D;B 'y 2*G* with e&e"tro&ytes( vitamins( and minera&s* Mr* N "ontinued to have severe as"ites and 7H peda& edema( with redu"ed urinary output* 5e had some '&ood drawn again( and his '&ood N58 was now up to @7 units//* 5is prothrom'in time was in"reased a'ove the norma& range 'y 9 se"onds* 5is serum a&'umin was down to 7*% g/d/* ,!. was 7) the ,/. &eve&( and FF. was ?%% 2U//* New orders for Mr* N in"&uded the fo&&owing: $* !pirono&a"tone (,&da"tone) 2*G* 7* urosemide (/asi)) 2*G* 8* /a"tu&ose enema 9* Neomy"in via N/F tu'e ;* D;B at >; ""/hr .he physi"ian re-uested a nutrition "onsu&t for re"ommendations regarding an appropriate tu'e feeding and f&ow rate* 4N"- ST+N"IN5 T1- 0+T1/016SI/7/56 $* Define the fo&&owing terms: !engstaken-:&akemore tu'e (7 points)

.he !engstaken-:&akemore tu'e-is a tu'e to manage upper F2 distress* 2t is espe"ia&&y usefu& in providing temporary "ontro& of esophagea& vari"es that are '&eeding out* (,s seen in this patient)* 2t is usua&&y inserted through the nose or mouth of the patient( and is on&y a temporary so&ution to manage the '&eeding* .he tu'e with a def&ated 'a&&oon on the tip gets inserted unti& it rea"hes the esophagus and is inf&ated to app&y pressure to the '&eeding area*

a* 5epati" en"epha&opathy (,A, porta& systemi" en"epha&opathy) (7 points)

5epati" en"epha&opathy usua&&y o""urs in patients with "irrhosis* 2t is when a patient disp&ays a&tered &eve&s of "ons"ious a'i&ity (su"h as "onfusion or persona&ity "hanges) or "oma as a resu&t of &iver fai&ure or dysfun"tion whi"h affe"ts the &ivers a'i&ity to remove to)i" su'stan"es &ike ammonia from the 'ody* * :esides "ognitive symptoms( patients 'io&ogi"a&&y disp&ay a diversion of porta& '&ood into the systemi" "ir"u&ation through Porto systemi" "o&&atera& vesse&s*

'* ,steri)is (7 points)

,steri)is-is sometimes "a&&ed f&apping tremor* .he hand tremors when the wrist is e)tended* !ome say it resem'&es a 'ird f&apping its wings* .his disorder "an 'e a sign of hepati" en"epha&opathy "aused 'y damage to 'rain "e&&s sin"e the &iver is una'&e to meta'o&iIe ammonia to urea*

7* 1)p&ain the pathophysio&ogy of esophagea& vari"es and porta& hypertension as it re&ates to &iver disease and Mr* N3s '&eeding* (9 points)
Porta& hypertension (a""ording to "&ass notes%-is in"reased resistan"e to '&ood f&ow through the &iver* .his is "aused 'y fi'roti" reorganiIation of the norma& &iver set-up* 2t "auses in"reased '&ood pressure in the porta& vein* .his resu&ts in the deve&opment of "o&&atera& "ir"u&ation* .his is stating the "irrhosis of Mr* N is advan"ed* 5is &iver is taking a huge hit due to the a&"oho& a'use "ausing this porta& hypertension and &iver fai&ure* 1sophagea& vari"es- .hese are &arge veins in the &ower part of the esophagus* .his is happening 'e"ause norma& '&ood f&ow to the &iver is '&o"ked 'y s"ar tissue in the &iver* .his makes the '&ood find another route in sma&&er veins that are not designed to "arry that mu"h '&ood* .hese vesse&s "an &eak or rupture "ausing serious amounts of '&eeding* .his "an happen when the &iver rearranges itse&f due to the s"ar tissue "aused 'y "irrhosis and fi'rosis* *

8* Bhat is the re&ationship 'etween prothrom'in time and &iver diseaseK (9 points)
0n the "hart in the notes for hepati" disorders( it says if the prothrom'in time is higher( you get more points* More points ta&&ied up from this s"oring system( the more serious your &iver disease is* .he disease in your &iver is affe"ting your a'i&ity for your '&ood to "&ot* !in"e prothrom'in is made in the &iver( the &iver disease is going to diminish the effe"tiveness of those proteins( in"reasing the '&ood "&otting time*

9* Mr* N3s ,!. was 7L ,/. and FF. was ?%% 2U//* Bhat do ea"h of these findings te&& the physi"ian a'out Mr* N3s &iverK (9 points)
Bhen ,!. is 7) ,/. a&"oho&i" "irrhosis( and there is a high FF. it reaffirms a&"oho&i" "irrhosis* .hese are a&& synthesiIed in the &iver and these high ,!. and FF. &eve&s indi"ate serious &iver pro'&ems* Norma& FF. is &ess than ?; 2U// ,/. is more spe"ifi" to &iver dysfun"tion* Be do not have spe"ifi" ,!. and ,/. &eve&s( 'ut with high ,!. and the FF. we "an "on"&ude there is definite a&"oho&i" "irrhosis*

;* Bhat is the signifi"an"e of Mr* N3s ammonia &eve& 'eing e&evated prior to his '&eedingK Bhat is the signifi"an"e of it 'eing e&evated to an even greater degree , .1< his '&eedingK (9 points)
/iver deto)ifies '&ood ammonia to urea* 5is '&ood ammonia &eve&s the first time were 9%( and norma& range is a'out 7;-;%* .his means that his ammonia &eve&s in the '&ood are at a norma& range* !o it wasn3t rea&&y e&evated prior to the '&eeding* 5oweverMM 2n"reased '&ood ammonia is o'served in "irrhosis of the &iver* 2t a&so indi"ates that the &iver is una'&e to meta'o&iIe and rid of the ammonia* ,fter '&eeding( the gastro intestina& tra"t is present with proteins that are degraded to N58* .his "auses higher ammonia &eve&s than 'efore the '&eeding*

N4T ITI/N +SS-SSM-NT "ietary Inta8e "ata =* rom Mr* N3s typi"a& dietary intake( "a&"u&ate the tota& num'er of "a&ories he "onsumed* ,&so "a&"u&ate the energy distri'ution of "a&ories for protein( "ar'ohydrate( and fat* or this -uestion( you must use the 1)"hange /ists for Mea& P&anning (Use ,ppendi) 89 in the 'a"k of the Arause te)t: !ee pp* $$$%-$$7$ ($8th ed*) and Modu&e 222( 4,n 2ntrodu"tion to the 1)"hange /ists for Mea& P&anning6)( and "omp&ete ea"h of the steps out&ined 'e&ow( showing your "a&"u&ations* Step 1# Determine what ea"h food "ounts as( in terms of e)"hanges* P&ease "ount "ar'ohydrate that is designated as su"h under 40ther +ar'ohydrate6 or 4+om'ination6 &ists as simp&y 4+ar'ohydrate6 rather than 4!tar"h6( and then "ount these separate&y under 40ther +ar'ohydrates6 in the ta'&e for !tep 7* +omp&ete the ta'&e 'e&ow* (= points)

,rea89ast $= oI "offee ('&a"k) $ .'sp ha&f and ha&f $ tsp sugar 7 s&i"es 'read( white 7 .'sp 'utter (sti"k) 7unch Spaghetti with meat sauce: $ " "ooked spaghetti nood&es J " spaghetti sau"e $ oI "ooked ground 'eef $7 f& oI Godka "inner +hi"ken sandwi"h( gri&&ed ? f& oI Godka

Counts As (Specif !"changes# ree food *; fat $ "ar' other 7 star"h 7 saturated fat e)"hanges

8 star"h e)"hange $ star"h e)"hange $ medium fat meat e)"hange ? a&"oho& e)"hanges 8 "ar'ohydrates( 9 &ean meats ;*88 a&"oho& e)"hanges

>

Step 2# ,dd the tota&s from the ta'&e in step $* +ount a&& items that were &isted anywhere 'esides the 4!.,<+56 &ist( that "ounted as "ar'ohydrate e)"hanges( under the 40ther "ar'ohydrate6 se"tion in the ta'&e 'e&ow* +ount as star"hes 0N/Y those foods &isted spe"ifi"a&&y on the !.,<+5 &ist* ($% points) -2chan:e 5roup !tar"h Non-!tar"hy Gegeta'&es ruit 0ther +ar'ohydrates at- ree Mi&k ($/7 E) /ow- at Mi&k ($E) <edu"ed- at Mi&k (7E) Bho&e Mi&k Gery /ean Meats/!u'stitutes /ean Meats/!u'stitutes Medium at Meats/!u'stitutes 5igh at Meats/!u'stitutes ats T/T+7 :ra%s "eter%ine 8cals &y %ultiplyin: T/T+7 :ra%s +lcohol e>ui!alent +lcohol Calories (1 alcohol e>ui!alent < 100 calories* 5 +N" T/T+7 ?C+7S (C1/ @ protein @ 9at @ alcohol* 7*; $;% ; 4<600 9 $ 9 =%
$7 $7 $7 $7 % % ? ? ? ? > > % 8 ; ? Use % 8

.ota& servings/ day =

+50 (g)
$;

Protein (g)
8

at (g)
Use %

@%
; $; $;

$?
7 % %

%
% % %

7?
% >

$7
;

>
% % > %

;
? ;

$7*; ;8 ;4 <212 $8*88 $(888 79$%*; 7@*; ;'< 265=5

Step 3# Determine the E k"a&s provided 'y +50* ($ point) =%%/79$%*;)$%%N79*@E

Step 4# Determine the E k"a&s provided 'y protein* ($ point)

7$7/79$%*;)$%%N?*?E

Step 5# Determine the E k"a&s provided 'y fat* ($ point) 7=;*;/79$%*;)$%%N$$*%E

Step 6# Determine the E k"a&s provided 'y a&"oho&* ($ point) $(888/79$%*;)$%%N;;*8E

+nthropo%etric "ata >* a* Bhi"h 'ody weight wi&& you use as the most 4a""urate6 weight to ref&e"t his 4a"tua&6 or 4dry6 'ody weight for your assessmentK 1LP/,2N your thinking* (8 points)
$9% &'s( 'e"ause this is 'efore his edema and as"ites whi"h add e)"ess weight* * !o he is e)treme&y underweight* 2t is very important to use "aution with these patients who have "irrhosis and hepati" fai&ure* 2t is important to take note of the "omp&i"ations of as"ites( edema and porta& hypertension and their effe"ts on weight*

'* !$aluate the weight you "hose in part > a* in terms of E idea& 'ody weight using the 5amwi e-uation* (8 points) "* Ma&e-$%=H =)$$N$>7 E idea& 'ody weight $9%/$>7 )$%%N?$*9E

"* !$aluate the weight you "hose in part > a in terms of "hange from usua& 'ody weight over time ('e spe"ifi")* 2f he has &ost weight( is it "&ini"a&&y signifi"antK 1)p&ain* (8 points) = months ago he was $>% $>%-$9%/$>% ) $%%N$>*=E in = months ,nything over $%E weight &oss is !1G1</Y signifi"ant as shown in the powerpoint of anthropometri"s* !o yes( this is "&ini"a&&y signifi"ant and shou&d 'e treated right away*

$%

?* 1va&uate Mr* N3s dietary intake( anthropometri"( P1/"&ini"a&( and 'io"hemi"a& data pertinent to his medi"a& status* Bhen appropriate( "ompare his data to standard/norma& va&ues* :e as thorough and !P1+2 2+ as possi'&e( and then clearly identi9y at least /N- pie"e of data that is o9 concern 9ro% a nutritional standpoint )ithin each data cate:ory as you 'egin to prioritiIe the most prominent nutrition issues that need to 'e addressed* -;07+IN your rationale 9or each issue that you %ention= a* "ietary inta8e data (<efer 'a"k to what you found in -uestion O= and eva&uate Mr* N3s intake in terms of maPor nutrients or food groups that appear to 'e &a"king( any o'vious pro'&ems you think he is having with intake) (7 points):

Mr* N is ingesting way too many "a&ories from a&"oho&* 2t is providing over ha&f of his "a&ori" intake* 5e is &a"king in fats( protein( and "ar'ohydrate* 5e needs to "ut out so mu"h a&"oho& to a&&ow for other nutrients and groups to 'e ingested ,ND a'sor'ed for his 'ody* 5e shou&d 'e "onsuming at &east 9%E of his intake from "ar'ohydrates and he is "onsuming mu"h &ess than that at rough&y 7;E* 5e is drinking Iero water or mi&k produ"ts* ,&& of his food groups are 'e&ow the re"ommended range*

'*

+nthropo%etric data (refer 'a"k to your answers in -uestion O>) (7 points):

5e &ost a !1G1<1 amount of weight in the past si) months* .he hamwi suggests he shou&d weigh thirty pounds more than he does right now for a hea&thy 'ody weight* 5e needs to gain weight* 5e has a&so &ost su'"utaneous fat and mus"&e*

$$

"*

0-3clinical 9indin:s (7 points):

5is "&ini"a& findings are showing mus"&e &oss* :ut my primary "on"ern wou&d 'e the edema and the as"ites* 5e has too mu"h f&uid 'ui&ding up whi"h is signifying serious &iver pro'&ems* 5e has de"reased urinary output and is throwing up 'right red '&ood* ,&& need to 'e addressed*

d*

,ioche%ical data (7 points):

$7

@* 1)p&ain the me"hanism of a"tion of the fo&&owing drugs( in terms of how it works to treat porta& systemi" en"epha&opathy* Determine any food-medi"ation intera"tions and nutrition re"ommendations for "onsumption* (= points) Medi"ation <ationa&e for Use/,"tion
Potassium sparing diureti"* 1ffe"tive for sodium e)"retion* .his is 'eing used to treat edema

ood-Medi"ation 2ntera"tions
Qust 'e "autious of foods/medi"ations that may make you retain more water whi&e on this drug*

Nutrition <e"ommendations
Bat"h high potassium supp&ements and foods sin"e those wi&& in"rease '&ood potassium &eve&s even more* ,&so monitor sa&t su'stitutes*

!pirono&a"tone (,&da"tone)

Potassium wasting diureti"* .his is 'eing used to treat edema*

urosemide (/asi))

2f you take this with a&"oho& it "ou&d &ower your '&ood pressure* .his "ou&d make you diIIy( faint( or "ou&d even "hange your heart rate .his drug "ou&d affe"t your '&ood sugar &eve& as we&&* 2t is a sugar produ"t* 2f you have dia'etes of '&ood sugar "on"erns it is important to dis"uss and monitor your '&ood sugar &eve&s*

.his may redu"e the potassium &eve&s in your '&ood* You may need to in"rease foods high in potassium in your diet*

+onsume with mi&k produ"ts

/a"tu&ose

.reats "onstipation 'y 'reaking down in the "o&on and pu&&ing water out from the 'ody to soften stoo&s*

Neomy"in

De"reases the 'a"teria that produ"e N58 in the gut* 2t is a preventative measure for hepati" en"epha&opathy* 2t wi&& keep ammonia &eve&s down*

!toma"h sensitivity* .here wasn3t mu"h information avai&a'&e

!toma"h sensitity* :e "arefu& of pro'ioti"s* .here wasn3t mu"h information avai&a'&e*

$8

Calculation o9 Nutrient Needs $%* <efer to the guide&ines given in 4Modu&e 22: 1nergy( Protein( and &uid <e-uirements in the +&ini"a& !etting6 and the 1,/ to "omp&ete the fo&&owing* !how your work and spe"ify the sour"e for your answers( and e)p&ain your reasoning for making the "hoi"es you made* ,* Using an appropriate predi"tion e-uation (with or without a"tivity/stress or inPury fa"tor( as you deem appropriate)( estimate Mr* N3s total ener:y re>uire%ent* ,s a&ways( e)p&ain your thinking and show your work* (9 points)

,""ording to the notes( predi"tion e-uations are used to estimate energy re-uirements when 2ndire"t +a&orimetry is unavai&a'&e* 5is <11 is avai&a'&e and is $>7%k"a&/ day* 5owever( we wi&& sti&& use the 5arris-:enedi"t e-uation Ma&esN <M<N ==*9> H $8*>;(=8*= kg) H;($?%*8)- =*>=(9;) ==*9>H?>9*;H@%$*;-8%9*7N$(;8? we wou&d then mu&tip&y it 'y a .11 fa"tor for aggressive weight gain .11N$*;N2$30A8cal3day (in"&uding .11 fa"tor) 5eightN>$ in"hes ) 7*;9N$?%*8 "m BeightN$9%/7*7N=8*= kg Be used this predi"tion e-uation 'e"ause when his <11 was measured he was i&& and sedentary* Be shou&d measure his "a&ori" needs and take into "onsideration that he needs to gain weight( not stay at this weight*

:*

Cross-chec8 your ans)er 9ound in 10+ &y calculatin: )hat your assessed total ener:y re>uire%ent is on a 8cal38: &asis= You do this 'y taking the tota& energy re-uirement estimated 'y your predi"tion e-uation method and dividing it 'y Mr* N3s weight to get k"a&/kg* 5ow does the num'er you "a&"u&ate "ompare to the "onsensus num'ers provided in Modu&e 22 (i*e* is it within the range of what <Ds tend to use( even though this pra"ti"e is not eviden"e-'ased per se)K !how your "a&"u&ations* (7 points)

$9% &'s/7*7N=8*= kg 8;k"a&/kg (higher end 'e"ause he is so underweight)N2$22A=3 8cals 0ur predi"tion e-uation resu&ted in s&ight&y higher k"a&/day( 'ut it was near the same range*

$9

+*

1stimate Mr* N3s protein re-uirement* 1)p&ain your thinking and show your work* (7 points)

Protein intake is $*7-$*; g/kg $*8g)=8*= kgN?7*> grams/day* Be used this range 'e"ause the 1!P1N guide&ines on 1ntera& Nutrition for /iver "irrhosis re"ommend the protein intake $*7-$*; g/kg

D*

Using guide&ines given in Modu&e 22( estimate Mr* N3s 9luid needs* !how your work* (7 points)

8; m&/kg a""ording to Modu&e 7 that he shou&d have 7*7 / per day* 5owever( sin"e Mr* N has as"ites and edema( he "ou&d 'e restri"ted to $-$*; / per day a""ording to Management of "omp&i"ations of ,s"ites and edema*

$;

N4T ITI/N "I+5N/SIS $$* :ased on your assessment in -uestion O ? ( refer to the Qensen arti"&e (Qensen F/( 5siao PY( Bhee&er D* ,du&t Nutrition ,ssessment .utoria&* % &arenter !nteral Nutr 7%$7C8=(8): 7=>-7>9*) and the ,!P1N/,"ademy +onsensus !tatement (Bhite QG( Fuenter P( Qensen F/( Ma&one ,( !"hofie&d M* +onsensus !tatement of the ,"ademy of Nutrition and Dieteti"s/,meri"an !o"iety for Parentera& and 1ntera& Nutrition: +hara"teristi"s <e"ommended for the 2dentifi"ation and Do"umentation of ,du&t Ma&nutrition (Undernutrition)* % &arenter !nteral Nutr 7%$7C8=(8):7>;-7?8*) to deter%ine i9 Mr= N %eets the de9inition o9 a speci9ic cate:ory o9 %alnutrition= -2plain your rationale= (7 points) 5e has "hroni" disease ma&nutrition* ,""ording to the white arti"&e( if the patient disp&ays organ fai&ure and moderate inf&ammation( &ike Mr* N( he has "hroni" disease ma&nutritionC he a&so has "ompromised energy intake as we&& as "ompromised 'ody mass whi"h re&ates to ma&nutrition of some sort* !o we "on"&ude that he has "hroni" disease ma&nutrition "onsidering his "ompromised 'ody mass and "hroni" "irrhosis*

$7* <efer to Modu&e 2: the Nutrition +are Pro"ess( Nutrition Diagnosis and Medi"a& <e"ord Do"umentation and your 2DN. <eferen"e Manua&* :ased on what you dis"overed in ear&ier -uestions( identi9y TB/ of Mr N3s %ost pro%inent nutrition-related pro&le%s within any of the domains (2N.,A1( +/2N2+,/ and/or :15,G20<,/1NG2<0NM1N.,/ D0M,2N!) using the standard Nutrition "ia:nostic Ter%inolo:y and INC74"- the C/"- C from the 2DN. manua& for ea"h nutrition diagnosis you write* 1ven if you determined in the pre"eding -uestion that he is ma&nourished( "hoose two nutritiona& diagnoses 0.51< than ma&nutrition that you "an address as the <D* 2n other words$ thin8 a&out the reasons )hy he is %alnourished as you identify his most important nutrition diagnoses* ,* Nutrition "ia:nosis C1# ($ point)

2nade-uate f&uid intake* N2-8*$

$=

:*

Nutrition "ia:nosis C2# ($ point)

2nade-uate energy intake* N2-$*7

$8* Now go 'a"k to your two nutrition diagnoses* For each one$ )rite a co%plete nutrition dia:nostic state%ent in 0-S 9or%at (pro&le%$ etiolo:y$ si:ns and sy%pto%s*$ la&elin: each section (0$ -$ and S* appropriately= 2dentify your short- and &ong-term goa&s( an appropriate intervention strategy to address the pro'&em( and measura'&e out"omes you wi&& monitor to eva&uate the effe"tiveness of your intervention* You may want to use Modu&e 22( your 2DN. manua&( and the 4Bhat is ,D2M16 do"ument on the "ourse we' site under 4<eferen"e Materia&s and <esour"es for +&ini"a& +ases6 to he&p you with this -uestion* ,* 0-S C1# (8 points)

2nade-uate f&uid intake(P) re&ated to high a&"oho& "onsumption and minima& water intake(1) as eviden"ed 'y &ow urinary output (!)*

:*

0-S C2# (8 points)

2nade-uate energy intake (P) re&ated to minima& energy( protein or fat sour"es from diet(1) as eviden"ed 'y severe weight &oss over the past si) months*

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N4T ITI/N INT- .-NTI/N$ M/NIT/ IN5$ +N" -.+74+TI/N -nteral Feedin: 2n the ne)t severa& -uestions( you wi&& 'e asked to deve&op an entera& feeding regimen for Mr* N* <egard&ess of how you assessed his energy and protein needs( and regard&ess of other fa"tors you might have "onsidered with regard to initiating nutrition support in Mr* N( please use the 9ollo)in: nu%&ers to do your calculations# -ner:y re-uirements: 2000 8cal 0rotein re-uirements: A5 - '5 : protein Fluid re-uirements: D1500 %7 N'(!: )se the sample calculation posted under *!nteral Nutrition Support+ on the we, site to guide ou through the calculations- N'(!: (hin. a,out choosing a more caloricall dense formula, li.e /sosource 0-1, in light of the fluid restriction- 2ou ma ha$e to ma.e our goal (3 ha$e the higher amount of protein to get 2444 .cals, and that5s o.a 6 thin. a,out how ou would start- 'r ou ma ha$e si7ed him up as ha$ing hepatorenal s ndrome- in which case, No$asource 8enal might ,e a ,etter choice- &ro$ide our rationale for whate$er option ou choose in the space ,elow$9* !e&e"t an appropriate formu&a from the <egion3s 5ospita& 1ntera& ormu&ary provided with the 1ntera& Nutrition !upport notes* 1)p&ain why you "hose this parti"u&ar formu&a( "iting the sour"e for your de"ision* (7 points) 2sosour"e $*;* 2 "hose this 'e"ause it is more "a&ori"a&&y and protein dense* Be "an monitor his f&uid intake 'y "hoosing this formu&a*

$;* Determine the vo&ume of formu&a needed to meet the estimated 7%%% k"a& energy re-uirement* (7 points) 7%%%k"a&/$*; (it3s $*; k"a&/m&)N$(888*88 m/N$*888 / or $(8%% m/

$?

$=* Determine the fina& step (goa& hour&y rate) in the feeding progression (for a 79-hour "ontinuous feeding)* <ound the rate to the nearest who&e num'er using the ru&e if R *;( round down( and if *; or a'ove( round up (e*g* if you "a&"u&ate that you need an hour&y rate of $%7*8 m& per hour round down to $%7( if you "a&"u&ate $%7*;( round up to $%8* (7 points)

$(888 m//79 hourN ;= m&/hour

$>* +a&"u&ate how mu"h energy and protein your fina& (goa&) rate wi&& provide* ,sk yourse&f if this vo&ume of formu&a wi&& meet assessed dai&y re-uirements for energy and protein (i*e* 7%%% k"a& and 'etween ;; D =% g protein)K (7 points) ;=m&/hour Provides $(899 m/ Protein-=? grams//)$*899N@7 grams protein (too mu"h protein) $899m/)$*; "a&oriesN7(%$=k"a& (meets k"a& re"ommendation)

$@

$?* +a&"u&ate the amount of additiona& water re-uired to meet f&uid needs (i*e* water f&ush)( assuming that Mr N3s hydration status is norma&( and that he is no &onger on any 2G hydration* (7 points) 2sosour"e is >?E f&uid $899)*>?N$(%9? m/ f&uid* 2 want to monitor his f&uid to $*; / per day (instead of 7*7 / that was "a&"u&ated 'e"ause of his as"ites and edema) so $(;%%-$(%9?N9;7 m&/day or 9;7/9N$$8

$@* +omp&ete the fo&&owing entera& order form( indi"ating the goa& . order( as per your "a&"u&ations a'ove* (; points) .he F0,/ . is: $899m/ (tota& 79-hour vo&ume) of 2sosour"e $*; (formula name) at the rate of ;=m/ per hour for 79 hours to provide a tota& of 77?*;g +50( @7 g protein( ?>g fat( 7(%$=k"a&s( $(%9?m/ free f&uid( with $$8 m/ of additiona& water f&ush provided 9 times per day* 7%* ,/N4S 5 points# Des"ri'e any "on"erns you have a'out initiating your . regimen in this patient( in &ight of his "urrent nutritiona& status* :e spe"ifi" a'out what you wi&& eva&uate 'efore you initiate the feeding( and how you wi&& progress the feeding so that you "an minimiIe risk to the patient* !tate what you wi&& monitor as you progress the feeding( so that you "an ensure that the patient is safe&y to&erating the feeding and that you are avoiding adverse "onse-uen"es as you advan"e the feeding to the goa& hour&y rate you have stated in -uestion O$@* 0ne "on"ern is refeeding syndrome* 0n day one( we shou&d on&y start 'y distri'uting enough formu&a to meet J of his goa& rate for k"a& and protein needs* 0n day two( we wi&& in"rease the tu'e feeding to meet S of his goa& for k"a& and protein needs* 0n day three we "an feed to his goa& rate for 'oth k"a& and protein needs* .his wi&& minimiIe the risk to the patient* Be wi&& monitor his e&e"tro&yte 'a&an"es( espe"ia&&y sodium( potassium and :UN &eve&s* Be wi&& a&so monitor his g&u"ose &eve&s* 2 wi&& monitor magnesium( potassium( and phosphorus whi&e refeeding* Be are determining how the patient rea"ts to the formu&a 'efore we "ontinue any more*

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