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
____________________ 1
A case study in partial fulfillment of the requirements in HNF 41, Diet Therapy I during the 2 nd semester 2009-2010 under the supervision of Ms. Lowela Padilla, UPLB, CHE, IHNF.
I.
Introduction
a. Concepts in Nutrition, Diet Therapy, and Organ System Concerned
A person’s 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, transport s, utilizes and excretes food substances (Lagua and Claudio, 2004).
The nourishment process is primarily attributed to digestion and absorption. Digestion is the body’s 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 intestin e, appendix, rectum, and anus. The principal functions of the gastrointestinal tract(GI) are the extraction of macronutrients, proteins, carbohyd rates 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
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).
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 body’s ability to metabolize the nutrients and bring about changes in body weight whenever necessary (Lagua and Claudio, 2004).
b. Importance/Significance of th e 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 subject’s 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 patient’s 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.
c.
Objectives o f th e St udy
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 patient’s 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 patient’s 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 patient’s relatives. These only support the credibility of the study. The following are the limitations of the study:
•
the interview with the patient’s relatives was only based on their own understanding from their observation on the patient’s 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 Director’s office. The researchers were referred to the Nursing Department to be facilitated on the records of the admitted patients. The medical record of
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
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 testicles—starting from an intra-abdominal location—normally 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
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 preexisting 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
•
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
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,
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 outle t from the stomach and inflammation or scarring from Crohn’s 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 Crohn’s 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 cause s of the
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).
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 Patien t – General Informa tion
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.
Physician’s Diagnosis/Impession
The patient was diagnosed with Complete Intestinal Obstruction secondary to Indirect Incarcerated Inguinal Hernia.
c.
Medical History
1. Chief c omplaint
The patient was brought to the hospital because he has experienced difficulty in breathing. 2. History of th e pre sent il lness
According to the hospital’s 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 father’s family history of having this disease. Other than that, there was no disease acquired by the patient.
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 father’s 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. Patient’s weight on February 24, 2010 was 4.9 kilograms. Patient gained 1.7 kilograms relative to his weight when he was confined.
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 formu la 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
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.
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. M e di ca t i o n
Ampicillin
Captopril
G e n e ri c Name Ampicillin
Brand Name MAY ampicillin
Captopril
Not indicated
I n di ca ti o n
C o nt ra i ndi ca ti o n
A dv e r s e R e a ct i o n
Infections caused by susceptible gm-ve & gm+ve bacteria
Hypersensitivity to penicillins, infectious mononucleosis
GI disturbances, skin rashes, pruritus, urticaria, fever, anaphylaxis, blood disorders, super infections.
It is used to treat high blood pressure (hypertension),
Kidney disease (if on dialysis), liver disease, heart
Fainting, urinating more or less than usual or not at all,
A dm i n i s t r a t i o n
Adult 500 mg 6 hrly IV or IM. Severe infections 150 mg/kg daily IV in equally divided doses every 3-4 hours. Children 25-50 mg/kg daily 6 hrly IV/IM. Severe infections 100-200 mg.kg daily given in divided doses every 3-4 hours starting with IV for 3 days then continue IM for the remaining days. For patients with either normal or low blood pressure
N u t ri e n t - D r u g Interactions Ampicillin may hinder the production of B vitamins and vitamin K.
Captopril
congestive heart failure, kidney problems caused by diabetes, and to improve survival after a heart attack.
disease or congestive heart failure; diabetes; or a connective tissue such as marfan syndrome, Sjogren’s syndrome, lupus, scleroderma, or rheumatoid arthritis.
fever, chills, body aches, flu symptoms; pale skin, easy bruising or bleeding, fast pounding or uneven heartbeats; chest pain, or swelling , rapid weight gain.
who have been vigorously treated with diuretics and who may be hyponatremic and/or hypovolemic, a starting dose of 6.25 or 12.5 mg 3 times a day may minimize the magnitude duration of the hypotensive effect for these patient. Titration to the usual daily dosagewithin can then occur the next several days.
Co-amoxiclav
Co-amoxiclav
Augmentin
Prophylaxisag ainst infections associated with major surgical procedures. Treatment of resp tract, GUT, skin & soft tissues, O &G infections.
Hypersensitivity to penicilllins. Contagious mononucleoisis. Penicillin associated jaundice or hepatic dysfunction.
Heart Failure initially 6.25 mg tid & gradually increase up to 59 mg tid. Erythematous Augmentin may be rash. Diarrhea, administered either pseudo by IV injection or membranous by intermittent colitis, indigenous, fusion. It is not nausea, vomiting, suitable for IM stomatitis & administration. candidiasis. Children 3 months -12yrs : usually 1.2 Erythema multiforme & g 8 hourly. In more other skin effects. serious infections,
Augmentin may hinder the production of B vitamins and vitamin K in the intestine.
Furosemide
Furosemide
Lasix
Edema dueto cardiac, hepatic & renal disease, burns; mild to moderate hypertension,
Anuria, hepatic coma, & precoma; severe hypokalamia&/or hyponatremia;
hypertensive crisis, acute heart failure, chronic renal failure, nephritic syndrome.
hypovolemia w/ or w/out hypotension. Hypersensitivity to furosemide or sulfonamides.
Hepatic, increase frequency hematological and to 6 hourly renal effects. intervals; 03months: 30 mg/kg Augmentin every 12 hrs In premature infants and full term infantsduring the prenatal period, increasing to 8 hours thereafter. Symptomatic Furosemide may be hypotension, administered IV or dehydration, Oral. hemoconcentratio n; hypokalemia, Tab adult initially hyponatremia, metabolic acidosis; increase of blood lipid levels, urea, uric acid; reduced glucose tolerance; hearing disorders, tinnitus; pancreatitis, GI symptoms; anaphylactic & anaphylactoid reactions, cutaneous reactions; fever, vasculitis, interstitial nephritis, hemolytic or
½ -1-2 tab daily. Maintenance: 1/2- 1 tab daily. Chldn2mg/kg body wt up to amax of 40 mg daily. Inj adult initially 20-40 mg IV/IM. If diuretic effect is not satisfactory dieresis is obtained, the dose should then be given once-bid.
Nutrients affected by drug:Calcium, , Licorice, Magnesium, Melatonin, Potassium, Vitamin B1Sodium , Vitamin B6, Vitamin C, Zinc.
Gentamicin
Gentamicin
Garamicin
Septicemia and serious infections of the CNS, respiratory
Lanoxin
Not indicated
Nutrients affected by drug are: Vit. B6, Calcium,
children 2 mg/kg 8 Magnesium, Chronic hrly. Potassium. recurrent UTI160 mg once daily. IM for 7-10 days. Cardiac Failure Intermittent Nausea, vomiting, Lanoxin should be May deplete accompanied by atrial complete heart block anorexia, diarrhea, taken by oral thiamine with long nd fibrillation; or 2 degree AV gynecomastia, formulation or term use. management of block esp if there is headache, through IV chronic cardiac a history of Stokesweakness, apathy, formulation. Using natural Oral Adult& failure where systolic Addam attacks; malaise, fatigue, licorice product children > 10 yr dysfunction or arrhythmia caused depression, may cause low rapid oral loading levels of potassium. ventricular dilation is by cardiac glycoside psychosis, visual dose 750-1500mcg dominant; intoxication, supradisturbance, management of ventricular ventricular as a single dose. Slow oral loading certain supraarrhythmia caused premature ventricular by Wolff-Parkinson- contractions atrial dose 250-750 mcg arrhythmias, White syndrome; or ventricular daily for 1 week particulary atrial ventricular arrhythmias & followed by an flutter and tachycardia or conduction appropriate
tract,tissues. GIT, skin and soft
Lanoxin
Hypersensitivity
aplastic anemia, leukocytopenia, agranulocytosis, thrombocytopenia, paraesthesia, photosensitivity, nephrolithiasis, nephrocalcinosis, & increased risk of persisitence of Botallo’s duct if used in premature infant. Adult 3-5 mg/kg. Ototoxicity and nephrotoxicity. body wt. older neonate &
fibrillation.
fibrillation; hypertrophic obstructive cardiomyopathy. Hypersensitivity to other digitalis glycosides.
effects, Intestinal ischemia. Rarely skin rashes and thrombocytopenia.
maintenance dose. Maintenance dose: usually 125-750 mcg/day or ≤ 62.5 mcg/day may suffice. Oral loading dose 5-10 years 25 mcg/kg. 25 yr 35 mcg/kg. Term neonates 2yr old 4 mcg/kg, preterm neonates 1.5 kg-2.5 kg30 mcg/kg 2-5yr 35 mcg/kg pre-term nenonates <1.5 kg 25 mcg/kg. doses taken per 24hr. inj 500-1000 mcg loading dose, depending on age, lean body weight and renal function. IV loading dose children 5-10yr25 mcg/kg, 2-5yr 35 mcg/kg, term neonates 2-yr35 mcg/kg, pre-term neonates 1.5-2.5kg 30 mcg/kg, preterm neonates < 1.5 kg 20 mcg/kg. doses taken over 24 hr. loading doses administered in
Metronidazole
Metronidazole
Rodazid Pharma nutria
Treatment of susceptible protozoal infections and in the treatment of prophylaxis of anaerobic bacterial
Nalbuphine
Nalbuphine
Nubaine
infections. Used for control of moderate to severe pain and as an adjunct to anesth.
Blood dyscrasia & active CNS disorder. Alcohol
GI discomfort, anorexia
Sedation, sweaty, clammy, nausea and vomiting, dizziness, vertigo, dry mouth and headache.
divided doses with ½ the total dose given as the first dose & the remainder given at 4-8 hrly intervals, assessing clinical response before giving each additional dose. Anaerobic infection & surgical chemo prophylaxis 20-30mg/kg per day
Not specified
Nubaine may be Not specified administered SC, IM or IV. The doses may be repeated every 3-6 hrs or as needed. Adult 70 kg body wt 10 mg S/MC/IV repeated 3-6 hrly. Non tolerant individualssingle max dose 20 mg, max total daily dose 160 mg induction of anesth0,3-3 mg/kg IV over 1015 min maintenance dose: .25-.5 mg/kg in single IV.
Paracetamol
Paracetamol
Tempra
Mild to moderate pain and fever
Ranitidine
Ranitidine
Pharex Ranitidine
Active duodenal ulcer, benign gastric ulcer, pathological hypersecretory
Renal or hepatic impairment; alcoholdependent patients; G6PD deficiency.
conditions, GERD, Erosive esophagitis,
Salbutamol
Salbutamol
Ventar
Relief bronchospasm in brochial asthma, chronic bronchitis, bronchiectasis, emphysema and other reversible obstructive pulmonary diseases.
Thyrotoxicosis, cardiac arrhythmias, coronary insufficiency, hypertension, ischematic heart disease. Diabetis mellitus, hyperthyroidism, ketoacidosis,
Nausea, allergic reactions, skin rashes, acute renal tubular necrosis. Potentially Fatal: Very rare, blood dyscrasias (e.g. thrombocytopenia, leucopenia, neutropenia, agranulocytosis); liver damage Headache, sometimes severe, rarely dizziness, insomnia,
May be taken with or without food. PO/Rectal 0.5-1 g 4-6 hrly when needed. Max: 4 g/day. IV >50 kg: 1 g 4-6 hrly (Max: 4 g/day); <50 kg: 15 mg/kg 4-6 hrly (Max: 60 mg/kg/day)
reversible mental confusion, reversible blurred vision, arrhythmias, constipation, diarrhea, nausea, vomiting, arthralgias, myalgias. Fine tremor of skeletal muscle particularly the hands, nausea, pounding heartbeat, nervousness or restlessness.
once daily bedtime forat4 weeks. Maintenance therapy: 150mg/kg at bedtime.
Not specified
Active duodenal Nutrients affected ulcer, active benign by drug: Folic Acid, gastric ulcer 150 Iron, Vitamin B12. mgbid or 300mg
Adult 200-400 mg 12 hrly. Children 100-200 mg 12 hrly.
May induce hypokalemia.
pheochromocytoma, sensitivity to symphatomimetics, ist trimester of pregnancy. rd Sources: MIMS Annual Philippines.2002. MediMedia: Singapore., MIMS Philippines 103 edition. 2005. Wong Mei Chan: Singapore. , Integrative Medical Arts Group Inc. IBISmedical.com. Copyright ©1998-2000, Naturalnews.com
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 R esults
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
below normal using the nutrition index of IRS which is weight-for-age. Patient’s 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 drug’s 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.
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, Sodium Vitamin 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)
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 patient’s 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 patient’s 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).
Table2. Complete Blood Count with Deviated Results (January 21, 2010) Laboratory Test
Normal Values
Actual Results
Lymphocyte
0.2-0.4
0.61
[Computed TLC]
[600-1200]
[1830]
MCV
86-100
MCH
26-31
Variance
Rationale for Variance
Increase
Malnutrition
76
Decrease
ChronicDisease
24.3
Decrease
ChronicDisease
Table3. CBG Result (January 21, 2010) Laboratory Test
Normal Values
Actual Results
CBG
44-115
119
Variance
Increase
Rationale for Variance
Duetoartificial glucose Infusion
Table4. Urinalysis with Deviated Results (January 21, 2010) Laboratory Test
Normal Values
Actual Results
Protein
<10mg/dLtrace
50 m g/dL+
Increase
Duetoartificial albumin Infusion (hyperoncotic albumin suspensions)
Bilirubin
<0.5 mg/dL+
2.0mg/dL++
Increase
ProlongedFasting
Acidic
Starvation
pH
6
5.5
Variance
Rationale for Variance
For the Roentgenological Test, the plain abdomen/cross-table lateral part of the patient’s body was observed. There is a bulging of the flambs with bowel distention. The bowels appeared centrally placed with differential air fluid levels. Ascites has not ruled out according to the roengenological test interpretation.
The patient’s kidneys and urinary bladder are also observed through Ultrasonography analysis. Kidneys are normal as well as the urinary bladder.
e.
Clinical A ssessment
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 patient’s scrotum.
As a manifestation of malnutrition, the patient has an old man’s face and muscle wasting. Also, his abdomen was swollen due to dilated intestine (Fishbein, 1977). Based on the patient’s 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.
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 man’s 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
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 antiinfective 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
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 mother’s 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 patient’s 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 patient’s 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:
· poor (<5g/kg/d), the infant requires full reassessment · moderate (5-10g/kg/d), check whether intake targets are being met, or if infection has been overlooked When the recommended diet prescribed will be followed, the expected weight of the patient is 6.2 kg which is his computed ideal body weight. Long-term Recommendation
Follow-up after recovery
A child who is 90% weight-for-length (equivalent to -1SD) can be considered to have recovered.
The child is still likely to have a low weight-for-age because of stunting. Good feeding practices
and sensory stimulation should be continued at home. Show parent or carer how to:-
· feed frequently with energy- and nutrient-dense foods
· give structured play therapy During his 8 th month of age (assuming that the patient has achieved his desirable body weight), the diet prescribed is 790 kcal C
130
P15 F25. His prescribed diet consists of infant
formula with 113g powdered milk, 1080 ml and 123g sugar. The infant formula is for 3-4 feedings per day with an amount of 300 ml per feeding. His diet prescription will increase as he grows old. Also, other foods aside from Marie biscuits will be introduce one at a time. The order of adding solid foods to the diet of the patient is as follows:
Order of adding solid foods 1. Cereals (such as rice and wheat) 2. 3. 4. 5. 6.
Fruits Vegetables Eggs Munggo or other dried beans Meat, fish, poultry
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 Guida nce 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
2-3 meals per day
Continue with mashed family foods
Depending on the child’s appetite, 1-2 snacks may be offered 3-4 meals per day
Start with 2-3 tablespoonfuls per feed, increasing gradually to ½ of a 250 ml cup
9-11 months
12-23 months
Finely chopped or mashed foods; and foods that baby can pick up
Family foods, chopped or mashed if necessary
Depending on the child’s appetite, 1-2 snacks may be offered 3-4 meals per day
½ of a 250 ml cup/bowl
½ of a 250 ml cup/bowl
Depending on the child’s appetite, 1-2 snacks may be offered From Infant and Young Child Feeding, World Health Organization.
Other Recommendations
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 patient’s 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 body’s 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.
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 Brunner’s 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 groi n or scrot um 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.
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 c ondition 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.
IX. References/Literature Cited th
Braubwald, Eugene et. al. Harrison’s Principles of Internal Medicine . 15 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.
Food Composition Tables . 1997. Food Nutrition and Research Institute.Department of Science and Technology.
Food Exchange List 2008. 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. Harrison’s Principles of Internal Medicine. USA: McGraw Hill. 2001.15th ed.
Mahan, Kathleen L. Sylvia Escott-Stump. Krause’s Food, Nutrition and Diet Therapy. 11th ed. Singapore: Elsevier PTE LTD. 2004.
Martin, Elizabeth A. et al. The Bantam Medical Dictionary. USA: Market Publishing
House Ltd. 2000.
MIMS Annual Philippines. MediMedia: Singapore.2002. MIMS Philippines 103rd edition. Wong Mei Chan: Singapore. 2005. Mindell, E, Hopkins V: Prescription Alternatives . New Canaan, CT: Keats Publishing, Inc,
1998; p. 336. Tanchoco, Celeste C. 1994. Diet Manual. 4th ed. Philippines: FNRI.
Tanchoco, Celeste C. 1994. Food Exchange List. 3rd Revision. Philippines: FNRI.
Tanchoco, Celeste C. 2000. Nutritional Guidelines for Filipinos. Philippines: FNRI.
Tanchoco, Celeste C. 2002. Recommended Energy and Nutrient Intakes.
Philippines: FNRI. Whitney, Eleanor. Sharon Wolfes. Understanding clinical and Dietary Nutrition. USA:
Wadsworth Publishing Company. 1999.
Augmentin side effects, nutrient depletions, herbal interactions and health notes.2007. retrieved February 27 2010 from http//:www.naturalnews.com.
Ampicillin side effects, nutrient depletions, herbal interactions and health notes.2007. retrieved February 27 2010 from http//:www.naturalnews.com.
Captopril side effects, nutrient depletions, herbal interactions and health notes.2007. Retrieved February 27 2010 from http//:www.naturalnews.com.
Lanoxin side effects, nutrient depletions, herbal interactions and health notes.2007. Retrieved February 27 2010 from http//:www.naturalnews.com.
Ranitidine side effects, nutrient depletions, herbal interactions and health notes.2007. retrieved February 27 2010 from http//:www.naturalnews.com.
Captopril.2010. retrieved February 27 2010 from http//:www.naturalnews.com.
Intestinal Obstruction.2010.retrieved February 27 2010 from http//:www.freeMD.com Intestinal Obstruction.2010. Retrieved February 27 2010 from http//:www.mayoclinic.com
Intestinal Obstruction.2010. retrieved February 27 2010 from http//:www.merck.com
Inguinal Hernia.2010. Retrieved February 27 2010 from http//:www.mayoclinic.com
Integrative Medical Arts Group Inc. IBISmedical.com. Copyright ©1998-2000, Intestinal Obstruction. 2001. Encyclopedia of Medicine by Tish Davidson. Retrieved March 4 2010 from http://www.freearticles.com
I.
Appendices
A. Nutrition Care Plan PROBLEM LIST: Classification of
MedicalProblem
Problem Diagnosis
NutritionalProblem
Intestinal Obstruction secondary to Indirect
Marasmus
Incarcerated Inguinal Hernia Physiolog
•
Malabsorption
•
Malnutrition
•
Pain and discomfort in the groin
•
Loss of appetite
•
Swollen scrotum around testicles •
Old man’s face
•
Muscle wasting
ical Findings Symptom
•
Abnormal Findings
Behavior
Vomiting and diarrhea
•
Swelling of the abdomen
•
Abdominal tenderness
•
Increase in lymphocyte levels
•
Clogged intestines (x-ray)
•
Increase in CBG levels
•
Increase in bilirubin levels
•
Urine pH of 5.5, acidic
•
Decreased albumin level -
Loss of appetite
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 man’s face Muscle wasting Sunken eyeballs and fontanels Swollen abdomen
OBJECTIVE •
•
Physician’s Diagnosis/Impression: Complete Intestinal Obstruction secondary to Indirect Incarcerated Inguinal Hernia. Medication prescription:
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) Normal Values
Hemoglobin
125-160
130
Normal
-
Hematocrit
0.38-0.50
0.39
Normal
-
WBC Count
5-10
Neutrophile
0.4-0.6
Actual Results
5.89
Variance
Rationale for Variance
Laboratory Test
Normal
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
ChronicDisease
MCH
26-31
24.3
Decrease
ChronicDisease
MCHC
310-370
319
Normal
MDV
9-13
0.00
Decrease
-
(January 21, 2010) Laboratory Test
Normal Values
CBG
44-115
Actual Results
119
Variance
Rationale for Variance
Increase
Malabsorption
Urinalysis (January 21, 2010) Normal Values
Protein
<10mg/dLtrace
50 mg/dL+
Increase
Dehydration
Bilirubin
<0.5 mg/dL +
2.0 mg/dL ++
Increase
Prolonged Fasting
Urobilirogen
<2.0mg/dL+
2.0mg/dL+
Glucose pH
Actual Results
<50 mg/dLtrace
Variance
Rationale for Variance
Laboratory Test
Normal
Negative
6
5.5
-
Acidic
Starvation
Blood
Negative
Negative
Normal
-
Ketone
Negative
Negative
Normal
-
Nitrite
Negative
Negative
Normal
-
Leukocytes
Negative
Negative
Normal
-
Clarity
Turbid
Turbid
Normal
-
SpecificGravity
1.010-1.025mg/ml
1.024
Color
DarkAmber
DarkAmber
Normal Normal
-
(January 24, 2010) Laboratory Test
Normal Values
Actual Results
Variance
Rationale for Variance
Sodium
135-145
141
Normal
-
Potassium
3.5-5.1
3.61
Normal
-
ASSESSMENT Anthropometric
Thenutritionalstatusoftheinfantupon admission was below normal using the nutrition index of IRS (weight-for-age)
Biochemical
The patient has distended abdomen because of the bulged flanks with bowel gas distention seen in the roentgenological report.
Clinical
Old man’s face and muscle wasting are evident due to severe malnutrition. Sunken eyeballs and fontanels There is a deformity in the patient’s scrotum
Dietary
PROGNOSIS Short-termObjective
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 of the patient will undergo the mother can produce breast milk already. nutrition counseling focusing on the If not the patient will continue taking advantages of the breastfeeding. formula milk The prescribed diet for the infant:
Diet Rx Energy 1050 kcal C150 P20 F30
This includes formula milk and Marie Biscuits
according to the actual intake of the infant. Achieve Catch up growth
LongtermObjective
Progress is assessed by the rate of weight gain. • Weigh child each morning before being fed. Plot weight. • Each week calculate and record weight gain as g/kg/d.
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 patient’s 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
Fooditems Marie crackers Formula Milk
Exchange/amount ¾ exchange
Energy(kcal) 75
140 g 930 ml 150 g
powdered milk Water Sugar Number of feedings: 4-5 times a day Amount per feeding: 210 ml
375 600
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 Marie
C (g) 17.25
P (g)
F (g) 1.5
E (kcal) -
75
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 ~ 15g CHON
Fluids 150 ml per kg IBW
Fluids = 150 ml × 6.2
= 930 ml
3. Determine the amount of milk needed
Milk
Kcal
Powderedwholemilk
Protein
40kcal/tbsp
2g/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 was subtracted by the amount of protein from the ¾ exchange of Marie biscuits which is 1.5 g).
= 18.5 g
2 g = 18.5 g 15 ml
(the required amount of protein of the infant for the milk formula)
(1 Tbsp= 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
= 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
= 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
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
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 Supplements Changes 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?
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
TimeandPlace Breakfast
AM Snacks
Lunch
PM Snack
Supper
MN Snack
Menu
Description
HHMeasure
Diet History
Fluid Usual fluid intake Recent change in amount Beverage preferences Frequency on intake Physiological A. Teeth/Mouth Teeth Condition Dentures Chewing Difficulties Soreness in mouth Swallowing Difficulties Choking Recent Changes in Taste B. Gastrointestinal Problems Excessive Belching Indigestion Nausea/Vomiting Bowels 1. Constipation or Diarrhea 2. Changes in m ovements 3. Frequency 4. Use of laxatives/enemas Urination Difficulties in urination
Anthropometric Data
Height Weight Circumferences: 1. MUAC 2. MAAC 3. Waist 4. Head Ratio: 1. Head/Chest
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 Creatinine Bilirubin
Clinical/Medical Information
Chief Complaint
Diagnosis
History of Present Illness
Drugs Prescribed Medication
GenericName
BrandName
Indication
Administration
Medical Procedures
D. Copy of Letter (Received Copy)
