| Course | NS490 Medical Nutrition Therapy II |
|---|---|
| Unit | Unit 3 |
| Paper type | Liver case workup |
| Length | About 1,110 words, 7 pages double-spaced |
| Format | APA 7 student paper |
| School | Purdue University Global |
| Program | BS in Nutrition Science |
| Updated | October 2026 |
Free sample paper for NS490 Unit 3
Against Cutting His Protein: A Unit 3 Liver Case Workup for Alcohol-Associated Hepatitis With Ascites and a First Episode of Confusion
[Student Name]
Purdue University Global
NS490: Medical Nutrition Therapy II
Unit 3 Liver Case Workup
[Instructor Name]
[Date]
The patient, the chart note and all values are composite; the two liver nutrition guidelines and the protein trial cited are real.
Case Presentation
Daniel, 44, a former line cook, was admitted with jaundice, abdominal swelling and two days of confusion. He has drunk heavily for fifteen years, about a fifth of whiskey a day in recent months. For the past three weeks he has eaten about one meal a day, usually a sandwich in the evening. His physicians have diagnosed alcohol-associated hepatitis on a background of probable cirrhosis, with moderate ascites and grade 2 hepatic encephalopathy, now improving on lactulose. A note from the overnight team suggests "limit protein to 40 g/day due to encephalopathy."
Assessment
Anthropometrics. Measured weight on admission is 84 kg; height 178 cm. His wife reports his usual weight was about 78 kg before the swelling began. Measured weight is inflated by ascites and leg edema, so it cannot be used directly for calculations.
Physical findings. Moderate ascites, swelling of both lower legs, marked loss of muscle at the temples, shoulders and thighs, and loss of fat over the triceps. Mild confusion, oriented to person and place.
Intake. About one meal a day for three weeks, estimated at 700 to 900 kcal and 25 to 35 g protein, plus alcohol.
Labs relevant to nutrition. Sodium 131 mEq/L, total bilirubin raised, international normalized ratio raised; magnesium and phosphate at the low end of normal.
Estimating Dry Weight
The liver nutrition guideline suggests estimating dry weight in patients with fluid retention by subtracting a percentage of measured weight according to the degree of ascites, about 10 percent for moderate ascites, with a further 5 percent for bilateral leg edema (Merli et al., 2019). For Daniel, 84 kg minus 15 percent is 84 times 0.85, or 71.4 kg. That is lower than his reported usual weight of 78 kg, which fits the muscle and fat loss seen on examination.
Estimated Needs
Energy. Guidance suggests at least 35 kcal per kilogram of dry weight for people with cirrhosis who are not obese (Merli et al., 2019). 35 times 71.4 equals about 2,500 kcal per day.
Protein. Both European liver nutrition guidelines set the protein goal for a malnourished patient with cirrhosis between 1.2 and 1.5 g a day for every kilogram he weighs (Merli et al., 2019; Plauth et al., 2019). 1.2 times 71.4 equals 86 g, and 1.5 times 71.4 equals 107 g.
The proposed limit of 40 g a day would give Daniel less than half the protein guidelines recommend for a malnourished patient with cirrhosis, at the moment his muscle loss is most visible.
Why Protein Should Not Be Cut
Restricting protein during hepatic encephalopathy was once standard, on the theory that dietary protein produces ammonia. A randomized trial tested this directly in patients with cirrhosis and episodic encephalopathy, comparing a low-protein diet with a normal-protein diet. Encephalopathy improved similarly in both groups, but patients on the low-protein diet broke down more body protein (Córdoba et al., 2004). Current guidelines therefore advise against protein restriction in encephalopathy, because it worsens muscle loss without improving the brain (Plauth et al., 2019). Muscle also helps clear ammonia, so losing it may make encephalopathy harder to control over time.
Why Muscle Matters Here
The muscle loss visible at Daniel's temples and thighs is not only a sign of malnutrition. In cirrhosis, low muscle mass is linked to more complications, longer hospital stays and higher mortality, and it can be present even when weight looks normal because fluid hides the loss. Skeletal muscle also takes up ammonia from the blood, so a patient who loses muscle loses part of his capacity to clear the compound that drives encephalopathy. That is the core of the case against cutting protein: a limit meant to reduce ammonia may, over weeks, reduce the tissue that removes it. Rebuilding muscle takes adequate protein, enough energy so that protein is not burned for fuel, and, once he is well enough, physical activity.
Alcohol and Recovery
Stopping alcohol is the most important step for his liver, and it also affects nutrition. Alcohol supplied some of his calories while displacing food, so stopping it will widen his energy gap unless meals increase. He will also be at risk of withdrawal in the first days of admission, which the medical team manages. A referral to addiction services before discharge gives the nutrition plan a chance to last.
Nutrition Diagnosis
Severe malnutrition in the context of chronic illness related to prolonged poor intake and alcohol use, as evidenced by intake well below needs for three weeks, marked muscle and fat loss, and an estimated dry weight 6.6 kg below his usual weight.
Recommendations
1. Do not restrict protein. Target 86 to 107 g per day, spread across the day.
2. Energy target about 2,500 kcal per day, starting lower and increasing over several days because of the risk of refeeding syndrome after weeks of poor intake. Electrolytes, especially phosphate, need daily checks while feeding is increased.
3. Small, frequent meals: breakfast, lunch, dinner and three snacks, including a late-evening snack with complex carbohydrate and protein, which guidelines recommend to shorten the overnight fast in cirrhosis (Merli et al., 2019).
4. Oral nutrition supplement between meals if intake is below 75 percent of target after 48 hours; consider tube feeding if intake stays inadequate.
5. Sodium limited to about 2 g per day for ascites; no fluid restriction unless sodium falls further.
6. Thiamine and other vitamins as prescribed by the medical team, given his alcohol history.
Communicating With the Team
The recommendation to remove the protein limit will be discussed with the attending physician and documented with the trial and guideline citations, rather than simply changing the order. The overnight note reflected an older practice, and a respectful explanation is more likely to change future orders than a silent correction.
Monitoring
Daily intake records, daily electrolytes for the first five days, weight daily with the understanding that changes reflect fluid, mental status as assessed by nursing, and grip strength weekly as a functional measure less affected by fluid.
Limitations
Dry weight is an estimate based on a percentage subtraction. Intake before admission is based on his wife's report, and she may not have seen everything he ate or drank during the day. Alcohol-associated hepatitis can change quickly, and the plan will be revised as his condition and mental status change.
References
Córdoba, J., López-Hellín, J., Planas, M., Sabín, P., Sanpedro, F., Castro, F., Esteban, R., & Guardia, J. (2004). Normal protein diet for episodic hepatic encephalopathy: Results of a randomized study. Journal of Hepatology, 41(1), 38-43. https://doi.org/10.1016/j.jhep.2004.03.023
Merli, M., Berzigotti, A., Zelber-Sagi, S., Dasarathy, S., Montagnese, S., Genton, L., Plauth, M., & Parés, A. (2019). EASL clinical practice guidelines on nutrition in chronic liver disease. Journal of Hepatology, 70(1), 172-193. https://doi.org/10.1016/j.jhep.2018.06.024
Plauth, M., Bernal, W., Dasarathy, S., Merli, M., Plank, L. D., Schütz, T., & Bischoff, S. C. (2019). ESPEN guideline on clinical nutrition in liver disease. Clinical Nutrition, 38(2), 485-521. https://doi.org/10.1016/j.clnu.2018.12.022
Reading the NS 490 Unit 3 instructions
This third unit of NS490 gives students a liver disease case and asks for a complete nutrition workup. Expect to assess intake, weight history, labs and physical signs, then estimate needs and write a nutrition diagnosis. Fluid makes weight unreliable in cirrhosis, so the prompt usually expects a stated method for dry weight. Protein is the classic point of debate, and the paper should take a position with current evidence. Address alcohol where it affects nutrition, such as thiamine, folate and calories from drinking. Recommendations should be specific about meals, snacks and supplements. Include how you would communicate with the medical team. A monitoring plan with labs and weights is expected. Workups like this typically fill five to seven pages in APA 7. Use current liver guidelines rather than older textbooks that still advise restricting protein.
How this NS490 Unit 3 example is built
The workup starts with Daniel's presentation and his three weeks of one meal a day. The assessment pulls together intake, labs, muscle wasting and the confusion that prompted a protein limit in his chart. Dry weight is estimated by subtracting a set share for moderate ascites, with the arithmetic shown. Energy and protein follow European liver guidance, calculated from that dry weight. The section arguing against cutting protein carries the highlighted sentence comparing the 40 g limit to what he needs. A short section explains why muscle loss matters for survival and for ammonia handling. Alcohol and recovery covers thiamine and appetite after stopping. The nutrition diagnosis is written in standard form. Recommendations add a late-evening snack and spread protein across the day. A note to the team explains the change, and monitoring and limitations close the workup.
Where the points sit in the NS490 Unit 3 rubric
Liver workups in this course are marked on a thorough assessment, a defensible estimate of needs and recommendations grounded in current evidence. The dry weight method must be named and shown, since everything else depends on it. The protein position counts heavily, and it should rest on guidelines rather than habit. A nutrition diagnosis in problem, etiology and signs form is commonly expected and graded on its fit with the assessment. Recommendations earn points when they are specific enough to follow. The communication section shows the student can advocate within a team. Monitoring with clear labs and timing is part of the rubric. Writing quality, logical headings and correct terms carry points. APA 7 with current references finishes the grade, and two European guidelines published in the same year are stronger than one older textbook.
NS490 Unit 3 help from the desk
The most damaging error in liver workups is accepting a protein restriction without checking the guidance, which can deepen muscle loss. Some writers calculate needs from a weight that includes several liters of ascites. Others skip the dry weight method entirely. Alcohol is sometimes discussed only as a behavior, without its nutrition effects. Recommendations stay general, such as eat more protein, without amounts or timing. The late-evening snack is often missed even though guidance supports it. Many workups never say how the team will be told. When your case includes confusion or ascites and you are unsure which weight to use or how firmly to argue, a writer from our team can prepare the workup to your patient's figures.
Get an NS490 Unit 3 example written to your instructions
Cirrhosis from another cause, a transplant evaluation or thinner labs may stand in for this patient in NS490 Unit 3. Forward the case notes, any guideline the course specifies and the rubric. The workup comes back with a dry-weight estimate shown, targets computed from it and every medical decision left with the team. Allow 24-48h; the first custom sample costs nothing. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.
More NS490 papers and BS in Nutrition Science samples
- NS490 Unit 1: Diabetes With Gastroparesis Post
- NS490 Unit 2: Plant-Forward Diet in Stage G4 CKD
- NS490 Unit 4: Enteral Regimen Worksheet
- NS490 Unit 5: Seminar Reflection
- NS490 Unit 6: Parenteral Nutrition Plan
- NS490 Unit 7: Critical Care Case Study
- NS490 Unit 8: Ethics Position Paper
- NS490 Unit 9: Transition and Discharge Plan
- NS490 Unit 10: Case Presentation
- NS480 Unit 3: Energy Needs After Femur Fracture
- NS105 Unit 3: Energy Calculation Set
- NS465 Unit 3: Functional Systems Matrix
- NS106 Unit 3: Scope of Practice Memo
NS490 Unit 3 questions, answered
How should dry weight be estimated with ascites?
Most course texts use a convention that subtracts a set percentage of measured weight depending on how much fluid is present, often 5, 10 and 15 percent for mild, moderate and severe ascites, or a post-paracentesis weight if one is recorded. Name the method, cite it, and state that the result is an estimate. A target calculated on the swollen weight will be too high.
Is branched-chain amino acid supplementation worth mentioning?
Briefly, where the case supports it. Guidance allows it for people who genuinely cannot tolerate enough protein from food, and some evidence links it to fewer complications. A paper that mentions it as an option for intolerance, with a citation, shows awareness without overstating what the supplement does for a typical patient.
Should the workup address alcohol use?
Yes, as it bears on nutrition: thiamine and folate status, the energy he drank rather than ate, and the likely effect of stopping on appetite. Treatment of alcohol use itself sits with the medical team and specialist services, and the workup should name that referral rather than attempt it.
Where can I find a free NS490 Unit 3 sample paper?
This page holds a complete NS490 Unit 3 liver case workup for a man with alcohol-associated hepatitis, ascites and confusion, from dry weight and protein needs to recommendations and monitoring.
Why does the NS490 Unit 3 sample reject the protein limit?
The proposed 40 g a day was less than half what European liver guidance recommends for a malnourished patient with cirrhosis. Restricting protein would worsen his muscle loss, which itself raises ammonia and risk.