hnf41 revised by lau_to be print (1)
TRANSCRIPT
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A Case Study of a 5-Month Old Male Infant
with Complete Intestinal Obstruction secondary to Incarcerated
Indirect Inguinal Hernia1
Carmina delas Alas
Marfil Mantica
Jacelyn Salvamante
Lara Jane Sarbues
Lauren Rose Tamondong
HNF 41 T-1L
____________________
1A case study in partial fulfillment of the requirements in HNF 41, Diet Therapy I during the 2nd
semester 2009-2010 under the supervision of Ms. Lowela Padilla, UPLB, CHE, IHNF.
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I. Introduction
a. Concepts in Nutrition, Diet Therapy, and Organ System Concerned
A persons health is affected by food intake because these are the objects that can be
taken to the body to yield energy and nutrients for the maintenance of life and the growth and
repair of the tissues (Whitney, 2005). Nutrition is the science of food, the nutrients and other
substances therein, their action, interaction and balance in relation to health and disease, and the
process which the organism ingests, digests, absorbs, transports, utilizes and excretes food
substances (Lagua and Claudio, 2004).
The nourishment process is primarily attributed to digestion and absorption. Digestion is
the bodys ingenious way of breaking down of foods into small units of nutrients in preparation
for absorption (Whitney, 2005). This process is done by the Digestive system. It is comprised
mainly by the mouth, pharynx, epiglottis, esophagus, esophageal sphincter, stomach, pyloric
sphincter, gallbladder, pancreas, small intestine, ileocecal valve, large intestine, appendix,
rectum, and anus. The principal functions of the gastrointestinal tract(GI) are the extraction of
macronutrients, proteins, carbohydrates lipids, water, and ethanol from ingested foods and
beverages, absorbance of crucial micronutrients and trace elements and serves as a physical and
immunologic barrier to microorganisms, foreign material and potential antigens consumed with
food or formed during the passage of food (Mahan and Escott-Stump, 2004).
The human GI tract could digest and absorb 92% to 97% of the foods being ingested
(Mahan and Escott-Stump, 2004). This study focuses on the small intestine. Principally, it is the
site of digestion and absorption for numerous nutrients. It is divided into three parts: duodenum,
jejunum, and ileum. The duodenum is about 0.5 meters long, the jejunum is 2 to 3 meters long
and the ileum is 3 to 4 meters long. The nutrients and minerals that are absorbed in this site are
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Chloride, Sulfate, Iron, Calcium, Magnesium, Zinc, Glucose, Galactose, Fructose, Vitamin C,
Thiamin, Riboflavin, Pyridoxine, Folic Acid, Amino Acids, Dipeptides, Tripeptides, Vitamins A,
D, E, K, Fats, Cholesterols, Bile Salts, and Vitamin B12 (Mahan and Escott-Stump, 2004).
Some of the common intestinal problems and diseases are Intestinal Gas and Flatulence,
Constipation, Diarrhea, Steatorrhea, Gastrointestinal Strictures and Obstruction, Celiac Disease,
Tropical Sprue and Hernias. The case study is about Hernia and Complete Intestinal Obstruction.
Hernia is the protrusion of an organ or tissue out of the body cavity in which it normally
lies (Martin, 2000). There are two common types of hernia Hiatal and Inguinal. This study
focused on Inguinal Hernia. Inguinal Hernia occurs when a section of the small intestine
protrudes through abdominal muscles, causing a lump in the groin. In men, the hernia often
protrudes into the scrotum, the sac that holds the testes. An inguinal hernia usually results from
weak abdominal muscles and increased pressure in the abdomen. This combination forces a loop
of intestine out through the weak area in the muscle wall. Obesity, heavy lifting, and prolonged
coughing can cause a hernia or make it worse (California Teachers Association, 2002). There are
two types of Inguinal Hernia Incarcerated and Strangulated. And as a diagnosis, the patient has
experienced an Indirect Incarcerated Inguinal Hernia. It is congenital and common to males than
in females because of the way males develop in the womb (National Institute of Diabetes and
Digestive and Kidney Diseases, 2010). Incarcerated Hernia can lead to a Strangulated Hernia in
which the blood supply to the incarcerated small intestine is put at risk (National National
Institute of Diabetes and Digestive and Kidney Diseases, 2010).
One of the complications of Indirect Incarcerated Inguinal Hernia is Intestinal
Obstruction. It results when the lumen is occluded at two points by single mechanism such as a
hernia ring or adhesive band, thus producing a closed loop wherein the blood supply is often
obstructed by the same time (Harrison, 2001).
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Upon the recurrence of these digestive problems, the role of diet therapy comes in. Diet
Therapy is the branch of dietetics that is concerned with the use of food to maintain good
nutritional status, correct deficiencies that may have occurred, afford rest to the whole body or to
certain organs that may be affected by disease, adjust the food intake to the bodys ability to
metabolize the nutrients and bring about changes in body weight whenever necessary (Lagua and
Claudio, 2004).
b. Importance/Significance of the Study
The diagnosed disease of the case patient could have noteworthy effects on the nutritional
status and consequent metabolic processes. Intestinal Obstruction and Incarcerated Inguinal
Hernia could cause inauspicious effects on the nutritional and health status of the patient. If this
diagnosed aberration is not treated appropriately, it could result to anatomic and physiologic
damages, and in due course, may put the subjects life at risk.
This study might also be accounted to be significant for it might provide crucial
information on the grounds of the above-stated disorders. Moreover, the assessment of the case
patients status might provide necessary data for further studies regarding the same disorder.
Lastly, this study would promote advocacy on the nutritional and health welfare of the case
patient and all concerned individuals.
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c. Objectives of the Study
The general objectives of the study are to explain the condition of the patient on having
Intestinal Obstruction Secondary Indirect Incarcerated Inguinal Hernia and to provide a
Nutritional Care Plan for the alleviation of the patients condition.
The specific objectives of the study are to:
describe the disorder condition of Incarcerated Inguinal Hernia and its relation to
Intestinal Obstruction;
interpret and analyze the biochemical test results of the patient to identify the causative
factors for the abovementioned disorders, if there is any;
examine the effects of prescribed drugs on the patients nutritional and health status;
assess the nutritional status and food intake nutrient adequacy of the patient using dietary
history such as the 24-hour food recall and anthropometric measurements such as weight,
height, etc., both for prior to admission and during hospitalization;
prepare an individualized and simplified therapeutic diet for the patient that would
improve the current nutritional and health status; and,
provide a Nutrition Care Plan for the patient that would include appropriate suggested
recommendations and specified nutritional interventions.
d. Limitations of the Study
The study was conducted with the available primary and secondary data obtained
from the hospital and the interview with the patients relatives. These only support the
credibility of the study. The following are the limitations of the study:
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the interview with the patients relatives was only based on their own
understanding from their observation on the patients condition;
The medications that were given to the patient are fully generic. The brand
names were not specified. Thus, some of the possible nutrient and drug
interactions cannot be determined specifically;
The dietary information was not completely stated in the medical record
because the amount of the food and the frequency of feeding are not all
specified.
An interview with the attending physician and nurse was not conducted.
Hence, additional information was not gathered;
The researchers are not technically inclined with medical knowledge;
The study has only focused on the intestinal obstruction and incarcerated
inguinal hernia. Other complications out of the topic would not be fully
discussed in the study;
The anthropometric data obtained are incomplete because the medical record
has only provided the weight of the patient.
II. Methodology
A request letter about the case patient with metabolic and gastrointestinal disorders was
provided by the HNF41 Faculty. It was submitted to the Ospital ng Muntinlupa. The letter has been
received on February 18, 2010 in the Hospital Directors office. The researchers were referred to the
Nursing Department to be facilitated on the records of the admitted patients. The medical record of
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the patient has been copied and an interview with the patient followed. The gathered data which
includes personal data, nutritional and dietary history, and other supporting documents, were
analyzed and assessed, and recommendations were suggested to the case patient.
III. Theoretical Consideration
1. Incarcerated Inguinal Hernia
A. Disease condition
An Inguinal hernia occurs when soft tissue usually part of the intestine protrudes
through a weak point or tear in the lower abdominal wall which results to a lump that can be
painful especially when a person cough, bend over or lift heavy object. When this happens, the
blood supply to the intestine is reduced, and the intestinal tissue starts to die.
An incarcerated indirect inguinal hernia is a condition wherein the hernia becomes stuck
in the groin or scrotum that cannot be put back to the abdomen. A part of the intestines protrudes
through an opening in the lower part of the abdomen, near the groin, called the inguinal canal. It
results from the failure of embryonic closure of the internal inguinal ring after the testicle has
passed through it. An inguinal hernia appears as a bulge on one or both sides of the groin. It may
occur any time from infancy to adulthood and is much more common in males than females. And
it may tend to become larger in time.
B. Classification/types
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Unlike inguinal hernia which occurs when a section of the small intestines protrudes to the
stomach muscles, Hiatal hernia occurs when there is a protrusion of a stomach part in the muscle
wall that separates the chest cavity from the abdominal cavity. This protrusion allows the stomach
contents to flow backward into the esophagus (The Carewise Guide, 1996).
An incarcerated inguinal hernia is caused by swelling and can lead to strangulated hernia,
causing the blood supply to the incarcerated small intestine to be jeopardized. A strangulated
hernia is a serious condition and requires immediate medical attention or surgery.
Direct and indirect hernias are the two types of inguinal hernia, and they have different
causes.
Indirect inguinal hernias, which are congenital hernias, are more common in males than
females because of the way males develop in the womb. In the male fetus, the spermatic cord and
both testiclesstarting from an intra-abdominal locationnormally descend through the inguinal
canal into the scrotum. Sometimes the entrance of the inguinal canal at the inguinal ring does not
close as it should just after birth, leaving a weakness in the abdominal wall. Fat or part of the
small intestine slides through the weakness into the inguinal canal, causing a hernia. In females,
an indirect inguinal hernia is caused by the female organs or the small intestine sliding into the
groin through a weakness in the abdominal wall (National Institute of Diabetes and Digestive and
Kidney Diseases, 2010). Indirect hernias are the most common type of inguinal hernia. Premature
infants are especially at risk for indirect inguinal hernias because there is less time for the
inguinal canal to close (National Institute of Diabetes and Digestive and Kidney Diseases, 2010).
Direct inguinal hernias are caused by connective tissue degeneration of the abdominal
muscles, which causes weakening of the muscles during the adult years. Direct inguinal hernias
occur usually in males. The hernia involves fat or the small intestine sliding through the weak
muscles into the groin. A direct hernia develops gradually because of continuous stress on the
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muscles. One or more of the following factors can cause pressure on the abdominal muscles and
may worsen the hernia:
sudden twists, pulls, or muscle strains
lifting heavy objects
straining on the toilet because of constipation
weight gain
chronic coughing
Indirect and direct inguinal hernias usually slide back and forth spontaneously through
the inguinal canal and can often be moved back into the abdomen with gentle massage (National
Institute of Diabetes and Digestive and Kidney Diseases, 2010).
C. Etiology
It might take a long time for a hernia to develop or it might develop suddenly. Many
Inguinal hernias occur as a result from the increased pressure in the abdominal wall, a pre-
existing weak spot in the abdominal wall or the combination of the two. Hernias may cause by a
combination of muscle weakness and strain, although the cause of the weakness and the type of
strain may vary. In these cases, straining the muscles does not cause the hernia but rather makes
the hernia more apparent. Some types of the strain on the body that may induce hernias are:
Obesity or sudden weight gain
Lifting heavy objects
Diarrhea or constipation
Persistent coughing or sneezing
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Pregnancy
Also, it usually occurs at birth when the abdominal lining or the peritoneum does not
close properly. Other Inguinal hernia develops through time when muscles deteriorate due to
factors such as aging, strenuous physical activity or coughing that accompanies smoking (Mayo
Clinic, 2010).
D. Incidence
Hernias are actually more common in babies and toddlers. And most teenagers who are
diagnosed with a hernia actually have had a weakness of the muscles or other abdominal tissues
from birth (called a congenital defect).
About five in every 100 children have inguinal hernias. Nearly 10 times more men than
women have inguinal hernias, and the vast majority of inguinal hernias are among boys (Mayo
Clinic, 2010).
E. Pathophysiology
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A hernia occurs when intra-abdominal contents traverse the ring to enter the inguinal
canal. As time passes, the hernia contents may enlarge, extend the length of the canal, and even
exit the canal through the external inguinal ring, an opening in the external oblique fascia, into
the scrotum (Mayo Clinic & Free MD, 2010).
Men are more likely to have an inherent weakness along the inguinal canal because of the
way males develop in the womb. In the male fetus, the testicles form within the abdomen and
then move down the inguinal canal into the scrotum. Shortly after birth, the inguinal canal closes
almost completely, leaving just enough room for the spermatic cord to pass through, but not large
enough to allow the testicles to move back into the abdomen (Mayo Clinic, 2010).
F. Clinical Manifestations and Underlying Mechanism
Clinical manifestations are pain and discomfort in the groin especially when bending or
lifting, a heavy and dragging sensation in the groin, and pain and swelling in the scrotum around
the testicles when the protruding intestine descends into the scrotum which happens in men
(Mayo Clinic, 2010).
2. Intestinal Obstruction
A. Disease condition
Intestinal obstruction is the blockage of the small intestine or colon that prevents food
and fluid from passing through it. The abnormal consequence of the obstruction depends on the
part in the gastrointestinal tract that becomes obstructed. If the obstruction occurs at the pylorus,
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then persistent vomiting of the stomach contents occurs. If obstruction is beyond the stomach
intestinal juices are vomited along with the stomach secretions (Mayo Clinic, 2010).
B. Classification/Type
Intestinal obstruction may be mechanical which is caused by intestinal adhesions,
hernias, tumors, twisting of the intestine, narrowing of the outlet from the stomach and
inflammation or scarring from Crohns disease. It may also be non-mechanical which is caused
by chemical, bacterial and circulatory diseases (Fishbein, 1977).
C. Etiology
Clinically, it is more useful to consider whether the obstructive mechanism involves the
small or large intestine because the causes are different (Harrison, 2001).
Mechanical obstruction in the small intestine can be caused by intestinal adhesions,
hernias, tumors, twisting of the intestine, narrowing of the outlet from the stomach and
inflammation or scarring from Crohns disease. Adhesions and external hernias are the most
common causes of the obstruction of the small intestine, constituting 70 to 75% of cases of this
type (Harrison, 2001).
Mechanical obstruction of the colon can be caused by cancer, diverticulitis, twisting of
the colon, narrowing of the colon and paralytic ileum. The most common causes of the
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obstruction of the colon which account 90% of the cases are carcinoma, sigmoid diverticulitis and
volvulus (Harrison, 2001).
The causes of non-mechanical intestinal obstruction are chemical, bacterial and
circulatory (Fishbein, 1977).
D. Incidence
Obstructions that are common in newborns and young children, especially in boys, are
the result of a twisting of the intestine that occurs when an inguinal hernia becomes incarcerated
(Fishbein, 1977).
E. Pathophysiology
Distention of the intestine is caused by the accumulation of gas and fluid proximal to and
within the obstructed segment. The accumulation of fluid proximal to the obstructing mechanisms
result not only from ingested fluid, swallowed saliva, gastric juice, and biliary and pancreatic
secretions but also from interference with normal sodium and water transport. After 24 hours of
obstruction, there is movement of sodium and water into the lumen, contributing to the distention
and fluid losses. Intraluminal pressure increases. Closed-loop obstruction of the small intestine
results when the lumen is occluded at two points by a single mechanism such as hernia ring or
adhesive band, thus producing a closed loop whose blood supply is often obstructed at the same
time. A form of closed-loop obstruction is encountered when complete obstruction of the colon
exists (Harrison, 2001).
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F. Clinical manifestation and underlying mechanism
Clinical manifestations of Intestinal obstruction are abdominal pain and swelling, nausea,
vomiting and diarrhea, swelling of the abdomen, abdominal tenderness (Mayo Clinic, 2010).
Distention of the abdomen and a bloated feeling occur because of a dilated intestine with a
complete obstruction (Fishbein, 1977).
IV. The Patient General Information
a. Personal Data
The patient is Matt Joven Cajipe, a 7-months old infant. He was born on September
20, 2009 at their house located at Trece Martirez, Cavite. His parents are Jonathan and Mary
Jane Cajipe.
The 21-year old father works as a farm caretaker at Batangas and earns 1000 pesos in
a week. He is a smoker with a family history of Cardiovascular Diseases.
On the other hand, the 18-year old mother is a plain housewife who takes care of two
children Matt Joven, the case patient and Mary Joyce who is two years in age. Their
residence house was provided by the owner of the farm where the father is working. The
Cajipe Family is Roman Catholic, a religion with few religion taboos.
b. Physicians Diagnosis/Impession
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The patient was diagnosed with Complete Intestinal Obstruction secondary to Indirect
Incarcerated Inguinal Hernia.
c. Medical History
1. Chief complaint
The patient was brought to the hospital because he has experienced
difficulty in breathing.
2. History of the present illness
According to the hospitals medical record, the patient started to have
productive cough and difficulty of breathing with fever two days prior to
admission. Also, he had poor appetite and did not drink milk
3. History of other illness in the past
The patient was diagnosed to have a congenital heart disease. It was
brought by his fathers family history of having this disease. Other than that,
there was no disease acquired by the patient.
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4. Family history
The patient has a congenital heart disease inherited from the family
side of his father.
5. Personal and social history
The patient lives with his family since birth. He might be exposed to
passive smoking because of his fathers vice.
d. Nutritional and Dietary History
The patient was admitted with a weight of 3.2 kilograms. He was admitted on
January 21, 2010. In January 27, 2010, the weight of the patient was 3.67 kilograms. He
gained 0.47 kilogram within a week prior to confinement in the hospital. Patients weight
on February 24, 2010 was 4.9 kilograms. Patient gained 1.7 kilograms relative to his
weight when he was confined.
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The infant was breastfed for only one week. The mother of the patient said that
her production of milk was stopped that is why she did not give her child breastmilk.
Then, the infant was given milk formula. The brand of milk formula that they were using
is Nestogen. The infant is also given water after taking the formula milk. The brand of the
formula milk that they were using was changed. Bona substituted Nestogen as prescribed
by the doctor. However, the infant took lesser amount. When the patient was five months
old, he was given solid food by her mother. The patient eats Marie biscuit. He consumes
one pack a day.
The infant is fed 6 times a day equivalent to 6 bottles of formula milk which
contains 3 scoops of milk and 180ml of water.
V. Treatment/Modifications
a. Dietary Intervention
The infant is given milk formula. The brand of milk formula that they were using
is Nestogen. According to the mother, the child is breastfed every three hours. There is no
definite amount of milk given to the child. The infant takes the milk formula in any
amount as tolerated. The infant is also given water, about 20-30ml, after taking the
formula milk. The brand of the formula milk that they were using was changed when he
was confined in the hospital. Nestogen was substituted by Bona as prescribed by the
doctor. There was no information gathered regarding the reason why the doctor
prescribed such brand of formula milk. However, the infant took the new brand of
formula milk for three days only. Usually the patient takes the formula milk six times a
day during his confinement in the hospital. However, the infant took lesser amount. The
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patient is used to taking Nestogen as formula milk. The attending physician ordered to
shift to Nestogen again.
When the patient was five months old, he was given solid food by her mother.
The patient eats Marie biscuit. He consumes one pack a day. Until now the patient eats
the biscuit.
The patient was also given Parenteral nutrition to meet his body needs for
nutrients. This is essential since he undergone a major surgery and he has poor appetite.
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B. Medical Intervention
1. Drugs Prescribed or Given
The management of many diseases requires drug therapy, frequently involving the use of multiple drugs (Krause, 2006). The patient
underwent several medical procedures while in the hospital. Certain drugs were given to the patient to alleviate his condition (Table1).
Table 1.Drug Information prescribed to the patient.
Medication Generic
Name
Brand
Name
Indication Contraindication Adverse Reaction Administration Nutrient-Drug
Interactions
Ampicillin Ampicillin MAYampicillin
Infections caused bysusceptible gm-ve &gm+ve bacteria
Hypersensitivity topenicillins,infectiousmononucleosis
GI disturbances,skin rashes,
pruritus, urticaria,fever, anaphylaxis,
blood disorders,super infections.
Adult 500 mg 6hrly IV or IM.Severe infections
150 mg/kg daily IVin equally divideddoses every 3-4hours. Children
25-50 mg/kg daily6 hrly IV/IM.
Severe infections100-200 mg.kgdaily given individed doses every3-4 hours startingwith IV for 3 daysthen continue IM
for the remainingdays.
Ampicillin mayhinder the
production of Bvitamins andvitamin K.
Captopril Captopril Notindicated
It is used to treat highblood pressure
(hypertension),
Kidney disease (ifon dialysis), liver
disease, heart
Fainting, urinatingmore or less than
usual or not at all,
For patients witheither normal or
low blood pressure
Captopril
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congestive heartfailure, kidney
problems caused bydiabetes, and to
improve survivalafter a heart attack.
disease orcongestive heart
failure; diabetes; ora connective tissue
such as marfansyndrome, Sjogrens
syndrome, lupus,scleroderma, or
rheumatoid arthritis.
fever, chills, bodyaches, flu
symptoms; paleskin, easy bruising
or bleeding, fastpounding or
uneven heartbeats;chest pain, or
swelling , rapid
weight gain.
who have beenvigorously treated
with diuretics andwho may be
hyponatremicand/or
hypovolemic, astarting dose of
6.25 or 12.5 mg 3
times a day mayminimize themagnitude durationof the hypotensiveeffect for these
patient. Titration tothe usual dailydosage can thenoccur within thenext several days.
Heart Failure
initially 6.25 mg tid& graduallyincrease up to 59mg tid.
Co-amoxiclav Co-amoxiclav Augmentin Prophylaxis againstinfections associatedwith major surgical
procedures.Treatment of resptract, GUT, skin &soft tissues, O &Ginfections.
Hypersensitivity topenicilllins.Contagiousmononucleoisis.Penicillin associated
jaundice or hepaticdysfunction.
Erythematousrash. Diarrhea,
pseudomembranouscolitis, indigenous,nausea, vomiting,stomatitis &candidiasis.Erythema
multiforme &other skin effects.
Augmentin may beadministered either
by IV injection orby intermittentfusion. It is notsuitable for IMadministration.Children 3 months
-12yrs : usually 1.2
g 8 hourly. In moreserious infections,
Augmentin mayhinder the
production of Bvitamins andvitamin K in theintestine.
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Hepatic,hematological and
renal effects.
increase frequencyto 6 hourly
intervals; 0-3months: 30 mg/kg
Augmentin every12 hrs In premature
infants and fullterm infantsduring
the prenatal period,
increasing to 8hours thereafter.
Furosemide Furosemide Lasix Edema due to
cardiac, hepatic &renal disease, burns;mild to moderatehypertension,hypertensive crisis,acute heart failure,chronic renal failure,nephritic syndrome.
Anuria, hepatic
coma, & precoma;severehypokalamia&/orhyponatremia;hypovolemia w/ orw/out hypotension.Hypersensitivity tofurosemide orsulfonamides.
Symptomatic
hypotension,dehydration,hemoconcentration; hypokalemia,hyponatremia,metabolicacidosis; increaseof blood lipidlevels, urea, uricacid; reducedglucose tolerance;hearing disorders,tinnitus;
pancreatitis, GIsymptoms;anaphylactic &anaphylactoidreactions,cutaneousreactions; fever,vasculitis,interstitial
nephritis,hemolytic or
Furosemide may be
administered IV orOral.
Tab adult initially -1-2 tab daily.Maintenance: 1/2- 1tab daily.Chldn2mg/kg bodywt up to amax of 40mg daily. Inj adult
initially 20-40 mgIV/IM. If diureticeffect is not
satisfactory dieresisis obtained, thedose should then begiven once-bid.
Nutrients affected
by drug: Calcium,Licorice,Magnesium,Melatonin,Potassium,SodiumVitamin B1,Vitamin B6,Vitamin C,Zinc.
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aplastic anemia,leukocytopenia,
agranulocytosis,thrombocytopenia,
paraesthesia,photosensitivity,
nephrolithiasis,nephrocalcinosis,
& increased risk
of persisitence ofBotallos duct ifused in prematureinfant.
Gentamicin Gentamicin Garamicin Septicemia andserious infections ofthe CNS, respiratorytract, GIT, skin andsoft tissues.
Hypersensitivity Ototoxicity andnephrotoxicity.
Adult 3-5 mg/kg.body wt. olderneonate &
children 2 mg/kg8hrly. Chronicrecurrent UTI 160mg once daily. IMfor 7-10 days.
Nutrients affectedby drug are: Vit. B6Calcium,Magnesium,Potassium.
Lanoxin Lanoxin Notindicated
Cardiac Failureaccompanied by atrialfibrillation;management of
chronic cardiacfailure where systolicdysfunction orventricular dilation isdominant;management ofcertain supra-ventriculararrhythmias,
particulary atrialflutter and
Intermittentcomplete heart blockor 2nd degree AV
block esp if there is
a history of Stokes-Addam attacks;arrhythmia caused
by cardiac glycosideintoxication, supra-ventriculararrhythmia caused
by Wolff-Parkinson-White syndrome;ventriculartachycardia or
Nausea, vomiting,anorexia, diarrhea,gynecomastia,headache,
weakness, apathy,malaise, fatigue,depression,
psychosis, visualdisturbance,ventricular
prematurecontractions atrialor ventriculararrhythmias &conduction
Lanoxin should betaken by oralformulation orthrough IV
formulation.Oral Adult&
children > 10 yr
rapid oral loading
dose 750-1500mcgas a single dose.Slow oral loading
dose 250-750 mcgdaily for 1 weekfollowed by anappropriate
May depletethiamine with longterm use.
Using naturallicorice productmay cause lowlevels of potassium
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fibrillation. fibrillation;hypertrophic
obstructivecardiomyopathy.
Hypersensitivity toother digitalis
glycosides.
effects, Intestinalischemia. Rarely
skin rashes andthrombocytopenia.
maintenance dose.Maintenance dose:
usually 125-750mcg/day or 62.5
mcg/day maysuffice. Oral
loading dose 5-10
years 25 mcg/kg. 2-5 yr 35 mcg/kg.
Term neonates 2yrold 4 mcg/kg, pre-term neonates 1.5
kg-2.5 kg 30mcg/kg 2-5yr 35mcg/kg pre-termnenonates
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divided doses with the total dose
given as the firstdose & the
remainder given at4-8 hrly intervals,
assessing clinicalresponse before
giving each
additional dose.Metronidazole Metronidazole Rodazid
Pharma
nutria
Treatment ofsusceptible protozoal
infections and in thetreatment of
prophylaxis ofanaerobic bacterialinfections.
Blood dyscrasia &active CNS disorder.
Alcohol
GI discomfort,anorexia
Anaerobic
infection &
surgical chemo
prophylaxis
20-30mg/kg perday
Not specified
Nalbuphine Nalbuphine Nubaine Used for control of moderate to severe
pain and as anadjunct to anesth.
Sedation, sweaty,clammy, nauseaand vomiting,dizziness, vertigo,dry mouth andheadache.
Nubaine may beadministered SC,IM or IV. Thedoses may berepeated every 3-6hrs or as needed.Adult 70 kg body
wt 10 mg S/MC/IV
repeated 3-6 hrly.Non tolerant
individuals singlemax dose 20 mg,max total daily dose160 mg inductionof anesth 0,3-3mg/kg IV over 10-15 min maintenancedose: .25-.5 mg/kgin single IV.
Not specified
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Paracetamol Paracetamol Tempra Mild to moderatepain and fever
Renal or hepaticimpairment; alcohol-
dependent patients;G6PD deficiency.
Nausea, allergicreactions, skin
rashes, acute renaltubular necrosis.Potentially Fatal:
Very rare, blood
dyscrasias (e.g.thrombocytopenia,
leucopenia,
neutropenia,agranulocytosis);liver damage
May be taken withor without food.
PO/Rectal0.5-1 g4-6 hrly when
needed. Max: 4g/day.IV>50 kg: 1
g 4-6 hrly (Max: 4g/day);
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pheochromocytoma,sensitivity to
symphatomimetics,ist trimester of
pregnancy.
Sources: MIMS Annual Philippines.2002. MediMedia: Singapore., MIMS Philippines 103rdedition. 2005. Wong Mei Chan: Singapore. ,
Integrative Medical Arts Group Inc. IBISmedical.com. Copyright 1998-2000, Naturalnews.com
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2. Medical Treatment and Procedures (e.g. dialysis, insulin)
The patient has also undergone medical surgery. He has undergone
herniotomy to address the problem of hernia.
VI. Results and Evaluation
a. Disease Condition
Intestinal obstruction is a blockage of the small intestine or colon that prevents
passing of food and fluids. It can be caused by many conditions, with the patient it
was caused by hernia. Incarcerated inguinal hernia causes the obstruction of the small
intestine of the infant. Hernia is a mechanical obstruction that physically blocks the
intestine. Inguinal hernia occurs when soft tissue, usually the intestine, protrudes
through a weak point in the lower abdominal wall. (Mayo Clinic, 2010)
Inguinal hernia developed when the testicle of the male infant move down
into the scrotum through the inguinal canal. The canal closes after the baby is born to
prevent the testicles from moving back into the abdomen. However, this area does
not close off completely. A loop of intestine can move into the inguinal canal through
the weakened area of the lower abdomen which causes the hernia (Mayo Clinic,
2010).
b. Anthropometric Results
Data about the weight of the infant upon admission and confinement are the
only info obtained about anthropometric data. In determining the nutritional status of
the patient, weight-for-age nutrition index of IRS was used. The patient was admitted
with a weight of 3.2 kilograms. Nutritional status of the infant upon admission was
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below normal using the nutrition index of IRS which is weight-for-age. Patients
weight on February 24, 2010 was 4.9 kilograms. Nutritional status of the infant after
one month of confinement was also below normal using the nutrition index of IRS
which is weight-for-age. There was no length of the patient indicated.
Weight-for-age is useful in determining a rough estimate of present
nutritional status. However, using this nutrition index has limitations. One of the
limitations is it does not distinguish between acute and chronic malnutrition. Another
limitation is the interpretation may be complicated by the incidence of edema.
Possible systematic error may occur when inaccurate information gotten from
incorrect age (IRS, 1978).
c. Nutrient-Drug Interaction
Medication can affect with the nutrient absorption. Medication can reduce or improve
nutrient absorption. On the other hand, it can also affect nutrient metabolism (Cataldo, 2002).
The following medication, with its nutrient interaction, was taken by the patient during his
confinement in the hospital.
Gentamicin
Gentamicin is known to affect certain vitamins, Vitamins B6 (pyridoxine), Calcium,
Magnesium and Potassium.
Research reported that the use of gentamicin can interfere with Vitamin B6 metabolism,
but Vitamin B6 supplementation can alter the effect of it without reducing the drugs efficacy.
Also it is reported that gentamicin can cause urinary calcium, magnesium and potassium loss
and kidney damage (www.IBISmedical.com). Though there are reported interference of the
drug with Vitamin B6 metabolism, the patient was not given a Vitamin B6 supplement.
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Furosemide
The drug may decrease appetite thus decreasing nutrient intake. This drug is diuretic and
is known to deplete potassium and the depletion may also affect the magnesium levels. Other
nutrients affected by drug: Calcium,Licorice, , Melatonin,Potassium,SodiumVitamin B1,
Vitamin B6, Vitamin C, and Zinc ( Naturalnews.com).
Ampicillin
Ampicillin may hinder in the production of B vitamins and vitamin K (Mindell and
Hopkins, 1998) (Naturalsnews.com).
Ranitidine
The nutrients known to be affected by the drug are Folic Acid, Iron, and Vitamin B12. It
is beneficial and recommended to supplement B-complex vitamins (Naturalnews.com).
Co-amoxiclav
Intake of augmentin may hinder the production of B-vitamins and vitamin K in the
intestine. It is recommended to undergo supplementation if prolonged used of the drug
(Naturalnews.com).
Lanoxin
Lanoxin may deplete thiamine with long term use and the use of natural licorice product
may cause low levels of potassium. It is recommended to undergo supplementation if
prolonged used of the drug (Naturalnews.com)
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Captopril
Captopril may increase serum potassium with potassium-sparing diuretics. Zinc levels are
possibly depleted (Naturalnews.com).
There is no specified nutrient-drug interaction regarding Metronidazole, Nalbuphine,
Paracetamol. However, research says that Salbutamol may induce Hypokalemia.
d. Laboratory Test Results/Biochemical Findings
The routine laboratory tests that the attending physician has requested are the Complete
Blood Count, Blood Glucose, Urinalysis, Sodium and Potassium. Other tests requested are
Roentgenological Analysis and Ultrasound. These routine tests could be used to assess
specific nutrient deficiencies, or they can be useful for screening and monitoring. The data
obtained from these tests which are constantly in patients medical records can be used to
confirm and strengthen nutrition assessments.
On the Complete Blood Count results, an increase in lymphocyte of 0.61 mg/dL and
when TLC was computed with a value of 1830 cells/uL, is remarkable and indicative of the
patients malnutrition. On the other hand, the sudden decrease by 76 mg/dL and 24.3 mg/dL
in Mean Cell Volume (MCV) and Mean Cell Hemoglobin (MCH) respectively are evident
that the patient has a Chronic Disease (See Table2). Moreover on the results of Blood
Glucose, it is notable that there is an increase by 119 mg/dL which could be accounted to the
infusion of artificial glucose (IV dextrose) (See Table3). Furthermore on the results of the
Urinalysis, there is a significant increase in protein by 50 mg/dL because of artificial amino
acid infusion (hyperoncotic suspension) administered to the patient and bilirubins with the
value of 2.0 mg/dL that would apparently verify that the patient has experiencing prolonged
fasting while the acidity of the urine by the pH of 6 would confirm that the patient was
experiencing starvation (See Table4).
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Table2. Complete Blood Count with Deviated Results (January 21, 2010)
Laboratory Test Normal Values Actual Results VarianceRationale for
Variance
Lymphocyte
[Computed TLC]
0.2-0.4
[600-1200]
0.61
[1830]Increase Malnutrition
MCV 86-100 76 Decrease Chronic Disease
MCH 26-31 24.3 Decrease Chronic Disease
Table3. CBG Result (January 21, 2010)
Laboratory
TestNormal Values Actual Results Variance
Rationale for
Variance
CBG 44-115 119 Increase Due to artificial
glucose Infusion
Table4. Urinalysis with Deviated Results (January 21, 2010)
Laboratory Test Normal ValuesActual
ResultsVariance
Rationale for
Variance
Protein
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The patients kidneys and urinary bladder are also observed through
Ultrasonography analysis. Kidneys are normal as well as the urinary bladder.
e. Clinical Assessment
The patient experienced different kind of signs and symptoms. Prior to
admission, the patient had experienced difficulty of breathing. In his medical record,
sunken eyeballs and fontanels were noted. Also, there was a deformity on the patients
scrotum.
As a manifestation of malnutrition, the patient has an old mans face and muscle
wasting. Also, his abdomen was swollen due to dilated intestine (Fishbein, 1977). Based
on the patients roentgenological report which examines plain abdomen or cross-table
lateral, the patient has bulged flanks with bowel gas distention. The bowels appear
centrally placed with differential air fluid levels. This information supports and explains
the condition of having a distended abdomen.
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VI. Nutritional Implication
As the intestine of the patient became congested, its ability to absorb nutrients decreased.
Decreased absorption may cause vomiting, dehydration and may even result to shock and can
cause kidney failure. In the case of the patient, his kidneys are normal in size with homogenous
parenchymal echopattern.
VII. Summary and Recommendations
The patient has a condition of complete intestinal obstruction secondary to incarcerated inguinal
hernia. This means that the hernia is physically blocking the intestine completely. Being a male
infant, inguinal hernia is more likely to occur. Because the testicles that have moved down into the
scrotum cannot move back to the abdomen at birth due to closed inguinal canal. This congenital
condition was a type of hernia that became stuck in the groin that cannot be massaged back to the
abdomen. Thus, herniotomy was conducted. Aside from these, the patient has a congenital heart
disease that he inherited from the side of his father.
The patient is malnourished as evidenced by his albumin level that is below normal. Physically,
muscle wasting is evident and the patient is marasmic, which means that he is both energy and protein
deficient. Old mans face is also evident in the patient as one of the clinical signs of malnutrition.
With these evidences, his nutritional status is related to the malabsorption of nutrients due to an
obstructed intestine. Also, two days before admission, the patient has a poor appetite and did not
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drink milk. These conditions may also contribute to the manifestation of malnutrition in the patient.
The patient was breastfed for one week. After that, his mother is giving him infant formula until
the present time. Also, the patient is beginning to eat solid foods while continuing bottle-feeding. His
parents often give him Marie biscuits and he can consume 1 pack per day that has 36 pieces.
As of February 24, 2010, the current weight of the patient is 4.9 kgs which is below normal for
his age. But compared to his weight before admission that is 3.2 kgs, he had gained 1.7 kgs in the
hospital for 1 month. Physically, his condition Also, there is no more muscle wasting though the
patient is still thin.
Short-term Recommendation
Breast milk is the important source of nutrients of an infant until two years
of age. As the infant grows and becomes more active, breast milk alone is not sufficient
to meet the nutritional needs of the infant. So complementary foods are needed to fill the
gap between the nutritional needs of the child and the amounts provided by the breast
milk. In the case of the patient, he was breastfed for only one week. Then, he was given
infant formula until at present. Even though the quantities of nutrients in the infant
formulas are adjusted to make them more comparable to breast milk, there are still
qualitative differences in the fat and protein that cannot be altered. Also, there is no anti-
infective and bio-active factors remain in the infant formulas. Powdered infant formula is
not a sterile product and may be unsafe if not prepared properly. Compared to infant
formula, breast milk is still the ideal food for the infant during the first six months of life.
With this, the mother must try breastfeeding her infant again little by little. It is
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recommended to refer the mother to consult with a physician or a dietitian regarding her
production of milk. Also, the mother must know the maternal benefit factors of
breastfeeding to encourage her of producing breast milk again. However, it is still
dependent on the mothers willingness and readiness to breastfeed. If not, the patient will
still be given infant formula as long as it can satisfy the nutritional requirements of the
infant.
For 4-8 weeks, the diet prescribed is 750 kcal with an additional 300 kcal to catch-up
the growth. The required energy is distributed into: C150 P20 F30. The prescribed diet consists
of infant formula with 140g powdered milk, 790 ml of water and 150g sugar. The Marie
biscuits are included in the prescribed diet since it was already introduced to the patient
by his mother. The amount of the biscuits is based on the patients actual intake which he
can tolerate (3/4 exchange of Marie biscuits).
If respirations increase by >5 breaths/min and pulse by >25 beats/min for two
successive 4-hourly readings, reduce the volume per feed.
After the period of 4-8 weeks, give frequent feeds (at least 4-hourly) of unlimited
amounts of a catch-up formula. Give an additional 150-220kcal/kg/d and 4-6g /kg/d of
protein in the patients requirement.
For monitoring, the progress is assessed by the rate of weight gain. Weigh the patient
each morning before being fed and record the weight. Each week calculate and record
weight gain as g/kg/d.
If weight gain is:
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poor (
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7. Other foods
It is recommended to give a teaspoonful or less at the beginning but the patient should
not be forced to eat more than he takes willingly. If the food is still being refused by the patient, it
must be omitted in the diet. For the texture, amount and frequency of solid foods recommended
as the infant grows old, see table 7.1.
Table 7.1. Practical Guidance on the quality, frequency and amount of food to offer
children 6-23 months of age
Age Texture Frequency Amount
6-8 months Start with thick
porridge, well
mashed foods
Continue with
mashed family
foods
2-3 meals per day
Depending on the
childs appetite,
1-2 snacks may
be offered
Start with 2-3
tablespoonfuls
per feed,
increasing
gradually to of
a 250 ml cup
9-11 months Finely chopped
or mashed foods;and foods that
baby can pick up
3-4 meals per day
Depending on the
childs appetite,
1-2 snacks may
be offered
of a 250 ml
cup/bowl
12-23 months Family foods,
chopped or
mashed if
necessary
3-4 meals per day
Depending on the
childs appetite,
1-2 snacks may
be offered
of a 250 ml
cup/bowl
From Infant and Young Child Feeding, World Health Organization.
Other Recommendations
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The weight of the patient should be regularly checked twice a month. By 5-6 months,
weight should be doubled. By 12 months, weight should be tripled. The patient will be
referred to a social worker regarding the patients financial needs during hospitalization
and regular check-up. Also, vitamin and mineral supplements for growth and
development of the infant are recommended. These supplements should be consulted
with a physician.
VIII. Glossary of Medical Terms and Abbreviations
Ascites an accumulation of fluid in the peritoneal cavity, causing abdominal swelling.
Causes include infections, heart failures, portal hypertension, cirrhosis, and various cancers.
Bilirubin bile pigments which are orange or yellow and the oxidized form of biliverdin
which is green. These give the brown color to the feces.
Chronic Disease a disease of long duration involving slow changes.
Diet Therapy the branch of dietetics that is concerned with the use of food to maintain
good nutritional status, correct deficiencies that may have occurred, afford rest to the whole
body or to certain organs that may be affected by disease, adjust the food intake to the bodys
ability to metabolize the nutrients and bring about changes in body weight whenever
necessary.
Diverticulitis inflammation of the diverticulum, most commonly of one or more colonic
diverticula. It is caused by infection and causes lower abdominal pain with diarrhea or
constipation; it may lead to abscess formation which often requires surgical drainage.
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Duodenum the first of the three parts of the small intestine that extends from the pylorus of
the stomach to the jejunum. It receives bile from the gall bladder and pancreatic juice from
the pancreas. Its walls contains various glands (including Brunners glands) that secrete an
alkaline juice (sucus entericus), rich in mucus, that protects the duodenum from the effects of
the acidic chime passing from the stomach.
External Oblique Fascia connective tissue that forming membranous layers of variable
thickness in the body.
Food anything that when taken into the body, serves to nourish, build and repair tissue.
Hernia the protrusion of an organ or tissue out of the body cavity in which it normally lies.
Herniotomy excision of the hernia sac: the first stage of the surgical repair of the hernia.
Hiatal Hernia it occurs when a part of the stomach protrudes above an opening in the
diaphragm, the muscle wall that separates the chest cavity from the abdominal cavity.
Ileum the lowest of the three portions of the small intestine that runs from the jejunum to
the ileocecal valve.
Indirect Incarcerated Inguinal Hernia - a condition wherein the hernia becomes stuck in
the groin or scrotum that cannot be put back to the abdomen. A part of the intestines
protrudes through an opening in the lower part of the abdomen, near the groin, called the
inguinal canal.
Inguinal Hernia - occurs when a section of the small intestine protrudes through abdominal
muscles, causing a lump in the groin. In men, the hernia often protrudes into the scrotum, the
sac that holds the testes.
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Intestinal Obstruction the blockage of the small intestine or colon that prevents food and
fluid from passing through it.
Jejunum the middle part of the small intestine. It comprises about two-fifths of the whole
small intestine and connects the duodenum to the ileum.
Nutrition the study of food in relation to health.
Omentum a double layer of peritoneum attached to the stomach and linking it with
abdominal organs, such as the liver, spleen and intestine.
Peritoneum the serous membrane of the abdominal cavity.
Roentgenological Analysis X-ray analysis
Scrotum the paired sac that holds the testes and epididymides outside the abdominal
cavity.
Strangulated Inguinal Hernia it is the condition when the blood supply to the incarcerated
small intestine is jeopardized.
Testicles either of the pair of male sex organs within the scrotum.
Ultrasonography the use ultrasound, usually in excess of 1 MHz to produce images of
structures of the human body that may be observed in the TV screen and subsequently
transferred to photographic films.
Urinalysis the analysis of urine using physical, chemical and microscopical tests to
determine the proportions of the normal constituents and to detect alcohol, drugs, sugar, or
other abnormal constituents.
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IX. References/Literature Cited
Braubwald, Eugene et. al.Harrisons Principles of Internal Medicine. 15th ed. McGraw-Hill
Medical Publishing Division: New York.2001.
Burnakis TG & Mioduch HJ: Combined therapy with captopril and potassium supplementation: a
potential for hyperkalemia. Arch Intern Med 1984; 144:2371-2372.
California Teachers Association [CTA]. The Carewise Guide. Washington: Academia
Press. 2002.
Cataldo C., Whitney E. and Rolfes S. Understanding Normal and Clinical Nutrition.
Thompson Wadsworth: USA.2002.
Claudio, Virginia S. et. al. Basic Diet Therapy for Filipinos. Philippines: Merriam and
Webster Inc. 1983.
Claudio, Virginia S. et al. Basic Nutrition for Filipinos. Manila: Merriam and Webster
Bookstore Inc. 2004. 5th ed.
Food and Nutrition Research Institute Department of Science and Technology
(FNRI-DOST). International Reference Standards. Philippines: FNRI. 1978.
Food, Nutrition and Research Institute. Department of Science and Technology.
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Food Composition Tables. 1997.
Food Nutrition and Research Institute.Department of Science and Technology.
Food Exchange List2008.
Food Nutrition and Research Institute.Department of Science and Technology.
Recommended Energy and Nutrient Allowances. 2002.
Lagua, Rosalinda T. and Virginia S. Claudio. Nutrition and Diet Therapy Dictionary
(Philippine Edition). Manila: Meriam Webster Bookstore. 2004.
Longo, Dan L., et al. Harrisons Principles of Internal Medicine. USA: McGraw Hill.
2001.15th ed.
Mahan, Kathleen L. Sylvia Escott-Stump. Krauses Food, Nutrition and Diet Therapy.
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I. Appendices
A. Nutrition Care Plan
PROBLEM LIST:
Classification of
ProblemMedical Problem Nutritional Problem
Diagnosis Intestinal Obstruction secondary to Indirect
Incarcerated Inguinal Hernia
Marasmus
Physiolog
ical
Findings
Malabsorption Malnutrition
Symptom Pain and discomfort in the groin
Swollen scrotum around testicles
Vomiting and diarrhea
Swelling of the abdomen
Abdominal tenderness
Increase in lymphocyte levels
Loss of appetite
Old mans face
Muscle wasting
Abnormal Findings Clogged intestines (x-ray)
Increase in CBG levels
Increase in bilirubin levels
Urine pH of 5.5, acidic
Decreased albumin level
Behavior - Loss of appetite
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SUBJECTIVE
Name: Matt Joven Cajipe
Age: 7 months old
Birth Date: September 20, 2009
Gender: Male
Address: Trece Martirez, Cavite
Occupation: N/A
Education attainment: N/A
Religion: Roman Catholic
Birth Weight: 3.2 kg
Weight upon Confinement: 3.2 kg
Chief Complaint:
Difficulty in Breathing
Cough
Signs of Nutritional Problem:
Loss of appetite
Old mans face
Muscle wasting
Sunken eyeballs and fontanels
Swollen abdomen
OBJECTIVE
Physicians Diagnosis/Impression: Complete Intestinal Obstruction secondary to
Indirect Incarcerated Inguinal Hernia.
Medication prescription:
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Gentamicin, Furosemide, Metronidazole, Ampicillin, Ranitidine, Paracetamol,
Co-amoxiclav, Nalbuphine, Lanoxin, Captopril
Nutritional Support: The patient was given IVF upon admission
LABORATORY TEST RESULTS
Complete Blood Count (January 21, 2010)
Laboratory Test Normal Values Actual Results VarianceRationale for
Variance
Hemoglobin 125-160 130 Normal -
Hematocrit 0.38-0.50 0.39 Normal -
WBC Count 5-10 5.89 Normal -
Neutrophile 0.4-0.6 0.21 Normal -
Basophile 0.0-0.1 0.00 Normal -
Lymphocyte 0.2-0.4 0.61 Increase Malnutrition
Monocyte 0.02-0.08 0.18 Increase
Reticulocyte 5-15 0.00 Decrease -
RBC count 4.56-5.5 4.56 Normal -
Platelet Count 150-350 220 Normal -
MCV 86-100 76 Decrease Chronic Disease
MCH 26-31 24.3 Decrease Chronic Disease
MCHC 310-370 319 Normal -
MDV 9-13 0.00 Decrease
(January 21, 2010)
Laboratory Test Normal Values Actual Results VarianceRationale for
Variance
CBG 44-115 119 Increase Malabsorption
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Urinalysis (January 21, 2010)
Laboratory Test Normal Values Actual Results VarianceRationale for
Variance
Protein
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ASSESSMENT
Anthropometric The nutritional status of the infant upon
admission was below normal using the
nutrition index of IRS (weight-for-age)
Biochemical
Clinical The patient has distended abdomen because of
the bulged flanks with bowel gas distention
seen in the roentgenological report.
Old mans face and muscle wasting are evident
due to severe malnutrition.
Sunken eyeballs and fontanels
There is a deformity in the patients scrotum
Dietary
PROGNOSIS
Short-term Objective Intervention
For 4-8 weeks, the patient is expected to:
Have an improvement in his disease
condition and enhance his appetite
Removal of hernia (herniotomy)
Be breastfed by the mother little by little if
the mother can produce breast milk already.
If not the patient will continue taking
formula milk
The mother of the patient will undergo
nutrition counseling focusing on the
advantages of the breastfeeding.
The prescribed diet for the infant:
Diet Rx Energy 1050 kcal C150 P20 F30
This includes formula milk and Marie Biscuits
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according to the actual intake of the infant.
Achieve Catch up growth Progress is assessed by the rate of weight gain.
Weigh child each morning before being fed.
Plot weight.
Each week calculate and record weight gainas g/kg/d.
Long term Objective Intervention
For 4-6 months, the patient should be able
to:
Attain and maintain his desirable body
weight
Follow his prescribed diet of solid foods
while still continuing taking formula
milk/breast milk (if the mother would still
be able to produce milk):
Diet Rx 790 kcal C130 P15 F25
Take his medications regularly until his
condition improves
Referral to a social worker regarding
patients financial needs
Take vitamin and mineral supplements for
growth and development
Refer to a doctor regarding the prescription
of supplements
Normalize biochemical values such as
protein, total lymphocyte count, bilirubin,
etc
Regular check-up and referral to a social
worker regarding hospital expenses
Meal plan:
Diet Rx Energy 1050 kcal C150 P20 F30
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Food items Exchange/amount Energy (kcal)
Marie crackers exchange 75
Formula Milk
powdered milk 140 g 375
Water 930 ml
Sugar 150 g 600Number of feedings: 4-5 times a day
Amount per feeding: 210 ml
TOTAL 1050
Long-term Recommendation (4-6 months)
Diet Rx Energy 790 kcal C130 P15 F25
Other Recommendations
Maintain healthy weight by eating a variety of foods and a balance diet. Do not smoke
later in life which may cause a chronic cough and can lead recurrence of inguinal hernia. Avoid
lifting heavy objects to prevent pressure on the abdominal muscles.
B. Computations
Short-term Recommendation
Food Item C (g) P (g) F (g) E (kcal)
Marie 17.25 1.5 - 75
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1. Determine the ideal body weight of the infant
For less than 6 mos :
IBW = BW (g) + (age in months 600)
= 3200 + (5 600)
= 3200 + 3000
= 6200 ~ 6.2 kg
2. Determine the nutrient requirements
Calories= 110-120 kcal per kg IBW
Calories = 120 kcal 6.2 kg
= 744 Kcal ~ 750 kcal
Protein= < 6 mos 1.5-2.5 g per kg IBW
CHON = 2.5g 6.2
= 15.5 ~ 15gCHON
Fluids 150 ml per kg IBW
Fluids = 150 ml 6.2
= 930 ml
3. Determine the amount of milk needed
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Milk Kcal Protein
Powdered whole milk 40 kcal/tbsp 2 g/Tbsp
a. The amount of milk to meet the protein requirement
Protein= 20 g -1.5g (the required amount of protein which is 15 g wassubtracted by the amount of protein from the
exchange of Marie biscuits which is 1.5 g).
= 18.5 g (the required amount of protein of the infant for the milk
formula)
2 g = 18.5 g (1 Tbsp= 15 ml)
15 ml x
x =138.75~ 140 g of powdered milk
40 kcal/tbsp= x/ 9.33tbsp (1Tbsp/15ml= x/101ml)
= 373.33 kcal~ 375 kcal (the caloric value of the amount of milk )
b. The amount of CHO to be added in the form of sugar
Total caloric requirement: 750 kcal
Total calories from the milk: 375 kcal
Total calories from the Marie Biscuits: 75 kcal
Sugar = 1050 kcal 450 kcal (the caloric values from the powdered milk and
marie biscuits were subtracted)
= 600 kcal/4kcal/g
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= 150 g of sugar
c. Amount of water to dilute the formula
930 ml 140 ml= 790 ml of water
Final formula
Powdered milk 140 g
Water 790 ml
Sugar 150 g
Size or amount of feeding
age in months + 2
5 + 2 = 7 oz per feeding (210 ml)
Number of feedings per day
= 930 ml/ 210ml
= 4.4 ~ 4-5 feedings/day
Long-term Recommendation
IBW = BW (g) + (age in months 600)
= 3200 + (8 500)
= 3200 + 4000
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= 7200 ~ 7.2 kg
Calories = 110 cal 7.2
= 792 ~ 790 kcal
CHON = 2g 7.2
= 14.4 ~ 15g
Fluids = 150 ml 7.2
= 1080 ml
Amount of Milk
2g/15ml = 15g/x
x = 112.5 ~ 112 g (300 kcal)
Sugar = 790 kcal 300 kcal
= 490 kcal/4kcal/g
=122.5 ~123 g
Size or amount of feeding
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8 + 2 = 10 oz (300 ml)
Number of feedings per day = 1080 ml/ 300ml
= 3.6 ~ 3-4 feedings/day
MONITORING AND EVALUATION
Regular checking of body weight twice a month. By 5-6 months, weight should
be doubled. By 12 months, weight should be tripled.
Undergo regular biochemical tests every month to check whether values of
bilirubin, protein, etc have normalized.
Regular consultation with a physician every month.
Regular consultation with a dietitian regarding his nutritional needs and for the
revision of nutritional care plan if the objectives are not met.
C. Questionnaire
Personal Data
Name
Age
Sex
Civil Status
Date of Birth
Place of Birth
Place of Residence
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Type of Residence
Occupation
Income Bracket
Socioeconomic Status
Religion and Belief
Religion Taboos
Hobbies/Recreation
Mother
Occupation
Medical History
Nutritional Status
Father
Occupation
Medical History
Nutritional Status
Name and Age of
Siblings
Personal Vices
Nutritional and Dietary Information
Food Preferences
Food Likes
Food Dislikes
Preferred Cooking Method
Food Allergies
SupplementsChanges in Body Weight
For Pediatric Cases: Breastfeeding and Weaning Information
Was the child breastfed?
If yes, for how long?
If not, why?
If not, what is the milk formula used?
What is frequency of feeding of milk formula?
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Exclusive or Complementary Feeding?
If Exclusive, what is the feeding frequency?
If Complementary, what milk formula?
If Complementary, what is the feeding frequency of milk formula?
Problems encountered:
24-hour Food Recall
Time and Place Menu Description HH Measure
Breakfast
AM Snacks
Lunch
PM Snack
Supper
MN Snack
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Diet History
Fluid
Usual fluid intakeRecent change in amount
Beverage preferences
Frequency on intake
Physiological
A. Teeth/Mouth
Teeth Condition
Dentures
Chewing Difficulties
Soreness in mouth
Swallowing Difficulties
ChokingRecent Changes in Taste
B. Gastrointestinal Problems
Excessive Belching
Indigestion
Nausea/Vomiting
Bowels
1. Constipation or Diarrhea
2. Changes in movements
3. Frequency
4. Use of laxatives/enemas
Urination
Difficulties in urination
Anthropometric Data
Height
WeightCircumferences:
1. MUAC
2. MAAC
3. Waist
4. Head
Ratio:
1. Head/Chest
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2. Waist/Hip
Body Mass Index
BMI Classification
Biochemical Test Results
Serum albumin
Serum transferrin
Serum cholesterol
Serum triglycerides
RBS/FBS
Hemoglobin
WBC
Lymphocytes
Total Lymphocyte Count
Blood Urea Nitrogen
CreatinineBilirubin
Clinical/Medical Information
Chief Complaint
Diagnosis
History of Present Illness
Drugs Prescribed
Medication Generic Name Brand Name Indication Administration
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Medical Procedures
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D. Copy of Letter (Received Copy)