Study Case 4GROUP MEMBERS :Nur Faten bt Abu Samah 0919308Nurul Alia Aqilah bt Samiun 0910124Norhafatini bt Aziz 0917272Nur Syafiqa bt Mohd Zulkefli 0915972Nur Athirah bt Amran 0918654
A 16 years old, Indian boy alleged with MVA. Hewas admitted to hospital with acute subduralhematoma. Decompressive craniectomy hasbeen done and patient was referred to dietitianfor 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."
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 NormalBIOCHEMICAL DATA valueSodium 137 mmol/L Normal 135-150 mmol/LPotassium 3.9 mmol/ L Normal 3.5-5.1 mmol / LUrea 5.0 mmol/L Normal 2.9-7.9 mmol/LCreatinine 44 µmol/L Normal 35-132 µmol/LAlbumin 39 g/L Normal 35-50 g/LTotal 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 Principle1. To provide Consume high biological value protein food per day such as animal derived food : meat, chicken, fish2. To minimize weight loss • Consume adequate calorie and nutritionally balance food per day • Avoid skipping meal3. To prevent infection Consume adequate intake of micronutrients to increase immune system4. 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.
CHO = 55 x 2000 = 1100 100 4 = 275 gPRO = 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 1Perative (RTU) 50 ml 3 hr / 8x /dkcal = 50 ml x 8 = 400 x 1.3 = 520 kcalCHO = 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 gFat = 0.0374 g x 50 ml = 1.87 g x 8 = 14.96 gIf pt can tolerate 1-2 feeding, go to step 2
Step 2Perative (RTU) 100 ml 3 hr / 8x /dkcal = 100 ml x 8 = 800 ml x 1.3 kcal = 1040 kcalCHO = 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 gFat = 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 3Perative (RTU) 150 ml 3 hr / 8x /dkcal = 150 ml x 8 = 1200 ml x 1.3 kcal = 1560 kcalCHO = 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 gFat = 0.0374 g x 150 ml = 5.61 g x 8 = 44.88 g
Add Modular formula = MCT oil to increasecalorie intake per day without increaseprotein intake. 10 ml 6 x/dKcal = 10 ml x 7.7 kcal = 77kcal x 6 = 462 kcalFat = 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 kcalTotal CHO = 212.64 gTotal PRO = 79.92 gTotal Fat = 44.8 g + 58.8 g = 103.68 g* Before and after feeding, flush with 30 ml water