Nursing case study hepatic encephalopathy

Alcoholic Cirrhosis

Mr. N is 58 y/o M (Ht 5’7” Adm Wt 160# and CBW 180 #) being treated for Laennec’s cirrhosis by PO diet and medications. As his condition worsened, a tube feeding became necessary. He developed ascites and pedal edema. His urinary output was decreasing. His diet consisted of the energy and protein levels recommended by the dietitian and a 1 g Na restriction; he did not like his diet at all. He ate sparingly and was not receiving the nutrients he needed. He continued to lose weight. After a few days without alcohol, he began to have delirium tremens (DT) and had to be restrained. During this time he began to hallucinate and use abusive language. He also started to exhibit asterixis. Blood NH3 was drawn and was 25 µmol/L. His intake dropped to almost nothing, and he was receiving only D5W (5% dextrose in water) by IV with added vitamins, minerals, and electrolytes. That night, Mr. N started vomiting large amounts of BRB (bright red blood). A Sengstaken-Blakemore tube had to be placed. Mr. N bled so much that whole blood had to be administered. His physician now added to Dx the following:

1. Hepatic encephalopathy (HE)

2. Portal hypertension

3. Esophageal varices

Mr. N was now in a semi-comatose state and had to keep the Sengstaken-Blakemore tube in place for another day. After the tube was removed, Mr. N had an N/G tube in place to low suction. Mr. N’s diet order was changed to NPO. He was receiving D5W by IV with electrolytes, vitamins, and minerals. Mr. N continued to have severe ascites and pedal edema with reduced urinary output. Mr. N had some blood drawn again and his NH3 was now up to 92 µmol/L. His prothrombin time was off by 4 seconds. His serum albumin was down to 2.2 g/dl. SGOT was 2x SGPT and GGTP was 800. New orders for Mr. N included the following:

1. Spironolactone (Aldactone) IV

2. Furosemide (Lasix) IV

3. Lactulose enema

4. Neomycin via N/G tube

5. D5W at 75 cc/hr

The physician called for the dietitian to recommend an appropriate tube feeding and amount.

QUESTIONS:

1. What is the mechanism of action for the following drugs: spironolactone (Aldactone) and furosemide (Lasix)?

2. What are the nutritional implications of these drugs, especially as they pertain to Mr. N’s condition?

3. Explain the mechanism of action of lactulose.

4. Explain the mechanism of action of neomycin sulfate.

5. Define the following terms:

· Portal hypertension:

· Esophageal varices:

· Sengstaken-Blakemore tube:

· Hepatic encephalopathy:

· Asterixis:

6. Explain the pathophysiology of esophageal varices and portal hypertension as it relates to liver disease and Mr. N’s bleeding.

7. What does it mean to have an N/G tube to low suction?

8. What is the relationship between prothrombin time and liver disease?

9. Mr. N’s AST was 2x ALT and GGTP was 800. What information does this provide the physician with concerning Mr. N’s liver?

10. What is the significance of Mr. N’s NH3 level being elevated prior to his bleeding? What is the significance of it being elevated to an even greater degree after his bleeding?

11. Before his bleeding, what diet prescription would have been appropriate for Mr. N? Be specific for protein, carb, fat, total energy, Na, fluids, vitamins, and minerals.

12. The tube feeding Mr. N should receive is obviously one designed for liver failure. List the characteristics of a hepatic TF and explain the reasoning behind each characteristic.

13. Are there any vitamins or minerals in particular that need to be added to a hepatic TF? Explain your answer.

14. Calculate Mr. N’s total energy needs using the Harris-Benedict formula and appropriate stress factor. Show your work.

15. Calculate his protein needs. Show your work.

16. Mr. N receiving D5W at 75 cc/hr. How many g of CHO is this? How many kcals? Show your work.

17. Considering the above, of the available enteral formulas, which one would you choose and why?

18. How much of this formula will Mr. N need to meet the requirements you previously calculated. Consider the IV kcals from D5W.

19. Give the starting strength and flow rate you would use and the progression to the final strength and flow rate. Explain your rationale.

20. Considering Mr. N is receiving lactulose and neomycin, can the TF be properly absorbed? Explain your answer.

Assume that Mr. N is going to recover from his hepatic encephalopathy; the edema and ascites will diminish significantly, and his renal function will return to normal. He will again be able to resume his diet. Also, assume that Mr. N will be discharged with end-stage cirrhosis and will not be able to drink alcohol at all. He will still have some edema and some ascites. His serum albumin will be very low, and he will be very weak.

21. Assuming that Mr. N will go home on a diet, estimate what that diet will be. Include in your estimate the number of kcals he should have, the grams and percent of protein, the grams and percent of carb, the grams and percent of fat, the cc of fluid, the grams of Na, and any other restrictions or supplements you feel necessary.