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Study Case 4

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A 16 years old, Indian boy alleged with MVA. He
was admitted to hospital with acute subdural
hematoma. Decompressive craniectomy has
been done and patient was referred to dietitian
for enteral Ryle’s tube feeding regime.
MVA (Motor vehicle
         accident )
 Major   cause of internal and external injury
 Motor vehicle accident injuries are as a
  direct result of the force of the impact
  and the biomechanics of injury. 
 Most motor vehicle accidents are the
  typical hyperextension flexion injuries, or
  more commonly known as "whiplash"
  injuries.
Acute subdural
           hematomas
 the  result of a serious head injury
 tiny veins between the surface of the
  brain and its outer covering (the dura)
  stretch and tear, allowing blood to
  collect.
 The bleeding fills the brain area very
  rapidly, compressing brain tissue.
 This often results in brain injury and may
  lead to death.
Decompressive
           Craniectomy
 the removal of a large area of skull to
  increase the potential volume of the
  cranial cavity
 aiming at reduction of raised intracranial
  pressure.
 At the beginning of the last century,
  Kocher asserted that "if there is no CSF
  pressure, but brain pressure exists, then
  pressure relief must be achieved by
  opening the skull."
Ryle’s tube feeding
o   nasogastric enteral feeding (adult
    feeding or stomach tube)
ANTHROPOMETRY DATA
 Height:   1.63m

 Weight    : 51kg

 BMI-for-age   percentiles (Boys, 2 to 20
 years)
 = 25th percentiles ( normal)
OBJECTIVE
 To provide suitable enteral feeding
  product
 To preserve lean body mass
 To increase protein synthesis
 To improve immune and muscle function
 To promote rapid recovery
 To shorten hospital stay
 To reduce the risk of morbidity
PRINCIPLES
 By providing suitable enteral product to
  achieve adequate calories and energy
  intake
 By giving high protein intake up to 1.5g/kg
  body weight to promote wound healing
 By educate patient and caregiver about
  hygiene and sanitation of enteral feeding
IMPLEMENTATION
 Elevate the head of the bed 30 to 45
  degree during feeding and 30 to 60
  minutes after bolus feeding.
 Tube feeding should be routinely flush with
  20 to 30 ml of water to prevent of
  occlution.
                  Value       Indication   Normal
BIOCHEMICAL DATA                            value
Sodium          137 mmol/L    Normal       135-150
                                           mmol/L
Potassium       3.9 mmol/ L    Normal       3.5-5.1
                                           mmol / L
Urea            5.0 mmol/L     Normal       2.9-7.9
                                           mmol/L
Creatinine      44 µmol/L      Normal       35-132
                                            µmol/L
Albumin           39 g/L       Normal      35-50 g/L
Total protein     70 g/L       Normal      60-80 g/L
NUTRITIONAL DIAGNOSIS (PES)

High protein requirement as related
  to acute subdural hematoma as
 evidence by post operative surgery
 
OBJECTIVE & PRINCIPLE
           Objective                           Principle
1. To provide                      Consume high biological value
                                   protein food per day such as
                                   animal derived food : meat,
                                   chicken, fish
2. To minimize weight loss         • Consume adequate calorie
                                   and nutritionally balance food
                                   per day
                                   • Avoid skipping meal
3. To prevent infection            Consume adequate intake of
                                   micronutrients to increase
                                   immune system

4. To inculcate hygiene practise   To educate patient and
                                   caregiver on hygiene of the tube
                                   by flushing with 30 ml of water
                                   before and after feeding.
NUTRITION INTERVENTION
   Calculation of Energy Requirements

   BMI= 19.19 Weight = 51kg Height = 163cm
    Age= 16 years old

 Harris – Benedict calculations
TEE = 66.5 + 13.8(W) + 5(H) – 6.8(A)
    = 66.5 + 13.8(51) + 5(163) – 6.8(16)
    = 1476.5 kcal/day
BEE = 1476.5 × AF × IF
     = 1476.5 × 1.2 × 1.3
     = 2303.34 kcal/day

* AF= 1.2 (in bed)             IF=1.3 (major surgery)
WHO Formula
BEE = 17.5 (W) + 651
   = 17.5 (51) + 651
   = 1543.5 kcal/day

Average calorie intake = 2303.34 + 1543.5
                                2
                        = 1923.42 kcal/day
                           ~ 2000 kcal/day
 
CHO =    55 x 2000 = 1100
        100            4
      = 275 g

PRO = 1.5 g/kg x 5.1 kg
    = 76.5 g x 4 x 100
          2000
    = 15.3 %

Fat   = 100% - 15.3% - 50%
      = 29.7 x 2000      = 594
        100                 9
      = 66 g
Step 1

Perative (RTU)

                 50 ml 3 hr / 8x /d

kcal = 50 ml x 8
     = 400 x 1.3
     = 520 kcal

CHO = 0.1772 g x 50 ml
    = 8.86 x 8
    = 70.88 g
PRO = 0.0666 g x 50 ml
    = 3.33 g x 8
    = 26.64 g

Fat   = 0.0374 g x 50 ml
      = 1.87 g x 8
      = 14.96 g

If pt can tolerate 1-2 feeding, go to step 2
Step 2

Perative (RTU)

                 100 ml    3 hr / 8x /d

kcal = 100 ml x 8
     = 800 ml x 1.3 kcal
     = 1040 kcal

CHO = 0.1772 g x 100 ml
    = 17.72 g x 8
    = 141.76 g
PRO = 0.0666 g x1500 ml
    = 6.66 g x 8
    = 53.28 g

Fat   = 0.0374 g x 100 ml
      = 3.74 g x 8
      = 29.92 g


      If pt can tolerate 1-2 feeding, go to step 3
Step 3

Perative (RTU)

            150 ml        3 hr / 8x /d

kcal = 150 ml x 8
     = 1200 ml x 1.3 kcal
     = 1560 kcal

CHO = 0.1772 g x 150 ml
    = 26.58 g x 8
    = 212.64 g
PRO = 0.0666 g x150 ml
    = 9.99 g x 8
    = 79.92 g

Fat   = 0.0374 g x 150 ml
      = 5.61 g x 8
      = 44.88 g
Add Modular formula = MCT oil to increase
calorie intake per day without increase
protein intake.

             10 ml          6 x/d

Kcal = 10 ml x 7.7 kcal
     = 77kcal x 6
     = 462 kcal

Fat   = 0.98 g/ml x 10 ml
            = 9.8 g x 6
            = 58.8 g
Thus , 150 ml Perative (8 times/day) + 10 ml MCT oil (6
  times/day) resulting :

Total calorie = 1560 kcal + 462 kcal
                = 2022 kcal

Total CHO    = 212.64 g

Total PRO   = 79.92 g

Total Fat     = 44.8 g + 58.8 g
              = 103.68 g

* Before and after feeding, flush with 30 ml water

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CASE STUDY 1 (Q4)

  • 1. Study Case 4 GROUP MEMBERS : Nur Faten bt Abu Samah 0919308 Nurul Alia Aqilah bt Samiun 0910124 Norhafatini bt Aziz 0917272 Nur Syafiqa bt Mohd Zulkefli 0915972 Nur Athirah bt Amran 0918654
  • 2. A 16 years old, Indian boy alleged with MVA. He was admitted to hospital with acute subdural hematoma. Decompressive craniectomy has been done and patient was referred to dietitian for enteral Ryle’s tube feeding regime.
  • 3. MVA (Motor vehicle accident )  Major cause of internal and external injury  Motor vehicle accident injuries are as a direct result of the force of the impact and the biomechanics of injury.   Most motor vehicle accidents are the typical hyperextension flexion injuries, or more commonly known as "whiplash" injuries.
  • 4. Acute subdural hematomas  the result of a serious head injury  tiny veins between the surface of the brain and its outer covering (the dura) stretch and tear, allowing blood to collect.  The bleeding fills the brain area very rapidly, compressing brain tissue.  This often results in brain injury and may lead to death.
  • 5. Decompressive Craniectomy  the removal of a large area of skull to increase the potential volume of the cranial cavity  aiming at reduction of raised intracranial pressure.  At the beginning of the last century, Kocher asserted that "if there is no CSF pressure, but brain pressure exists, then pressure relief must be achieved by opening the skull."
  • 6. Ryle’s tube feeding o nasogastric enteral feeding (adult feeding or stomach tube)
  • 7. ANTHROPOMETRY DATA  Height: 1.63m  Weight : 51kg  BMI-for-age percentiles (Boys, 2 to 20 years) = 25th percentiles ( normal)
  • 8. OBJECTIVE  To provide suitable enteral feeding product  To preserve lean body mass  To increase protein synthesis  To improve immune and muscle function  To promote rapid recovery  To shorten hospital stay  To reduce the risk of morbidity
  • 9. PRINCIPLES  By providing suitable enteral product to achieve adequate calories and energy intake  By giving high protein intake up to 1.5g/kg body weight to promote wound healing  By educate patient and caregiver about hygiene and sanitation of enteral feeding
  • 10. IMPLEMENTATION  Elevate the head of the bed 30 to 45 degree during feeding and 30 to 60 minutes after bolus feeding.  Tube feeding should be routinely flush with 20 to 30 ml of water to prevent of occlution.
  • 11.   Value Indication Normal BIOCHEMICAL DATA value Sodium 137 mmol/L Normal 135-150 mmol/L Potassium 3.9 mmol/ L Normal 3.5-5.1 mmol / L Urea 5.0 mmol/L Normal 2.9-7.9 mmol/L Creatinine 44 µmol/L Normal 35-132 µmol/L Albumin 39 g/L Normal 35-50 g/L Total protein 70 g/L Normal 60-80 g/L
  • 12. NUTRITIONAL DIAGNOSIS (PES) High protein requirement as related to acute subdural hematoma as evidence by post operative surgery
  • 13.   OBJECTIVE & PRINCIPLE Objective Principle 1. To provide Consume high biological value protein food per day such as animal derived food : meat, chicken, fish 2. To minimize weight loss • Consume adequate calorie and nutritionally balance food per day • Avoid skipping meal 3. To prevent infection Consume adequate intake of micronutrients to increase immune system 4. To inculcate hygiene practise To educate patient and caregiver on hygiene of the tube by flushing with 30 ml of water before and after feeding.
  • 14. NUTRITION INTERVENTION  Calculation of Energy Requirements  BMI= 19.19 Weight = 51kg Height = 163cm Age= 16 years old  Harris – Benedict calculations TEE = 66.5 + 13.8(W) + 5(H) – 6.8(A) = 66.5 + 13.8(51) + 5(163) – 6.8(16) = 1476.5 kcal/day BEE = 1476.5 × AF × IF = 1476.5 × 1.2 × 1.3 = 2303.34 kcal/day * AF= 1.2 (in bed) IF=1.3 (major surgery)
  • 15. WHO Formula BEE = 17.5 (W) + 651 = 17.5 (51) + 651 = 1543.5 kcal/day Average calorie intake = 2303.34 + 1543.5 2 = 1923.42 kcal/day ~ 2000 kcal/day  
  • 16. CHO = 55 x 2000 = 1100 100 4 = 275 g PRO = 1.5 g/kg x 5.1 kg = 76.5 g x 4 x 100 2000 = 15.3 % Fat = 100% - 15.3% - 50% = 29.7 x 2000 = 594 100 9 = 66 g
  • 17. Step 1 Perative (RTU) 50 ml 3 hr / 8x /d kcal = 50 ml x 8 = 400 x 1.3 = 520 kcal CHO = 0.1772 g x 50 ml = 8.86 x 8 = 70.88 g
  • 18. PRO = 0.0666 g x 50 ml = 3.33 g x 8 = 26.64 g Fat = 0.0374 g x 50 ml = 1.87 g x 8 = 14.96 g If pt can tolerate 1-2 feeding, go to step 2
  • 19. Step 2 Perative (RTU) 100 ml 3 hr / 8x /d kcal = 100 ml x 8 = 800 ml x 1.3 kcal = 1040 kcal CHO = 0.1772 g x 100 ml = 17.72 g x 8 = 141.76 g
  • 20. PRO = 0.0666 g x1500 ml = 6.66 g x 8 = 53.28 g Fat = 0.0374 g x 100 ml = 3.74 g x 8 = 29.92 g If pt can tolerate 1-2 feeding, go to step 3
  • 21. Step 3 Perative (RTU) 150 ml 3 hr / 8x /d kcal = 150 ml x 8 = 1200 ml x 1.3 kcal = 1560 kcal CHO = 0.1772 g x 150 ml = 26.58 g x 8 = 212.64 g
  • 22. PRO = 0.0666 g x150 ml = 9.99 g x 8 = 79.92 g Fat = 0.0374 g x 150 ml = 5.61 g x 8 = 44.88 g
  • 23. Add Modular formula = MCT oil to increase calorie intake per day without increase protein intake. 10 ml 6 x/d Kcal = 10 ml x 7.7 kcal = 77kcal x 6 = 462 kcal Fat = 0.98 g/ml x 10 ml = 9.8 g x 6 = 58.8 g
  • 24. Thus , 150 ml Perative (8 times/day) + 10 ml MCT oil (6 times/day) resulting : Total calorie = 1560 kcal + 462 kcal = 2022 kcal Total CHO = 212.64 g Total PRO = 79.92 g Total Fat = 44.8 g + 58.8 g = 103.68 g * Before and after feeding, flush with 30 ml water