1. Keeping the Numbers Simple: Bedside Tips for the Liver Patient ELIZABETH M. LIMOS, RN-D PHILIPPINE GENERAL HOSPITAL UNIVERSITY OF THE PHILIPPINES MANILA

2. Mini Nutritional Assessment MNA Last Name: ____________First Name: ______________ Sex: Age: Weight kg: Height cm: Date:_______ Complete the screen by filling in the boxes with the appropriate numbers. Add the numbers for the screen. If score is 11 or less, continue with the assessment to gain a Malnutrition Indicator Score.

5. Mini Nutritional Assessment MNA Last Name: ____________First Name: ______________ Sex: Age: Weight kg: Height cm: Date:_______ Complete the screen by filling in the boxes with the appropriate numbers. Add the numbers for the screen. If score is 11 or less, continue with the assessment to gain a Malnutrition Indicator Score.

7. Diet Recommendations High calorie (35 kcal/kg) Protein: Restricted at 0.6g to 0.8 g/k/d Normal at 1.0 to 1.2 g/k/d Sodium restriction Fluid restriction Increase dietary fiber Small frequent meals with bedtime snack

10. MEASURING YOUR FOOD To make sure your food servings are the right size, you can use: Food scale, Measuring cups, Measuring spoons

11. This much is the same as 3 ounces 1 serving of meat, chicken, turkey or fish 1 cup 1 serving of cooked vegetables salads casseroles or stews, such as chili with beans milk ½ cup 1 serving of fruit or fruit juice starchy vegetables, such as potatoes or corn pinto beans and other dried beans rice or noodles cereal 1 ounce 1 serving of snack food cheese (1 slice) 1 tablespoon 1 serving of salad dressing cream cheese 1 teaspoon 1 serving of margarine or butter oil mayonnaise

13. Case Scenario

14. CASE I 45 year old male, diagnosed to have chronic hepatitis B carrier with decompensated cirrhosis admitted due to body weakness and anorexia Vital signs: BP = 90/60 HR = 109 RR = 28 T = 37.3C Height = 5’6 (1.67meters) Weight = 45kgs

15. Physical Examination Pertinent findings: –Dry skin, Pale conjunctivae, Icteric sclerae –+ spider angiomata –Abdomen is globularly tense, +caput medusae, + ascites - + Grade 2 bipedal edema with skin hyperpigmenation

16. Laboratory Examinations CBC: Hgb = 9.7mg % Hct = 36 Albumin = 2.3 g/dl Protime = >3 sec prolonged Total Bilirubin = 7.6 gm/dl Sodium = 3.0 Potassium = 3.1

17. What is the nutritional status of the patient?

18. Ht = 5’ 6” = 66 inches x 2.54 = 167.64 cm DBW = Ht – 100 = 167.64 – 100 = 67.64 DBW = 67.64 – 6.764 = 60.87 or 61 kg

19. What is the nutritional status of the patient? % DBW = Actual body weight x 100 Desirable body weight = 45 kg x 100 61 kg = 74 % Moderate Malnutrition

20. How will you manage the nutritional status of the patient?

21. High calories (35 kcal/kg/d) Protein restriction (0.6g to 0.8g/kg/d) Sodium restriction Small frequent meals and bedtime snack Vitamin and mineral supplements as needed

22. How will you maintain the ideal weight of the patient despite her clinical condition?

23. DIETCALORIESPROTEIN(g) Low CHON diet 185549 Aminoleban Oral32020 (1-1/2 sachet) TOTAL 217569 (35kcal) (1.1g)

24. CASE 2 52 year old female, diabetic for more than 20 years, hypertensive, admitted due to poor appetite Vital signs:BP = 150/90 mm Hg HR = 105 RR = 30 T = 37.0 Height = 5’5 (1.64 meters) Weight = 40kgs

25. Physical Examination Pertinent findings: –Pale conjunctivae, dry skin, anicteric sclerae –+ spider angioma –Abdomen is flabby and soft, liver edge is nodular –+ grade 1 bipedal edema, +palmar erythema

26. Laboratory Examinations CBC: Hgb = 10.9 mg % Serum albumin = 2.8 gm Sodium = 2.8 gm/dl Potassium = 3.8 gm/dl FBS = 8.0 Creatinine = 2.3 mg/dl Ultrasound of the whole abdomen showed incidental finding of liver cirrhosis with ascites

27. What is the current nutritional status of the patient?

28. Ht = 5’ 5” = 65 inches x 2.54 = 165.1 cm DBW = Ht – 100 = 165.1 – 100 = 65.1 DBW = 65.1 – 6.51 = 58.59 or 59 kg

29. What is the current nutritional status of the patient? % DBW = Actual body weight x 100 Desirable body weight = 40 kg x 100 59 kg = 68 % Severe Malnutrition

30. How will you manage the nutritional derangement of the patient?

31. High calorie (35 kcal/kg) No protein restriction (1.1 g/kg/d) No simple sugar, complex carbohydrates Increase fiber intake Sodium restriction Frequent small meals

32. How will you maintain the ideal weight of the patient despite her clinical condition?

33. Calories = 2065 (35 kcal/kg) CHON = 65 gm (1.1g/k/d) CHO = 295 gm (65% NPC) Fat = 70 gm (35% NPC)