present ipd

8/8/2019 present ipd

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NURUS SA ADAH MOHD FADZIL0616952

AHD 4126:IPD 1Case presentation:UGIB & perinepric abscess



Introduction

Perinephric abscess (PNA) a.k.a perirenal abcess is defined as an abscess(infection) outside therenal capsule .They are rare in comparison to other infections involving the genitourinary tract but they can cause significant morbidity and mortality (Journal International Brazil Urology,2010).

R enal and perinephric abscess formation usually occur in patients with predisposing factors such

as diabetes mellitus, urinary calculi, urinary obstruction and immune compromised patients.Systemic diseases such as DM (46.9%) was much more common than renal or urologic diseasessuch as malignancy (4.1%) or renal stones (10.2%) (Seung Hwan Lee et al.,2010).

U pper gastrointestinal bleeding ( UGIB ) is defined as hemorrhage in the area of upper GI . oftencauses hematemesis (vomiting of blood) or melena (passage of stools rendered black and tarry bythe presence of altered blood) (Manish K Varma,2008) .

GI bleeding is a common complication of duodenal ulcers and can have serious consequences( Alan BR Thomson,2010) .



P reliminary data

Mr W (RN 654381)62/C/maleOccupation : gardenerMarital status : married + 3 childrenFamily background : wife- rubber tapperCaretaker : daughter only available at 7pm

everydayDOR: 22 Sept 2010 : High protein diet

DOA:12 Sept 2010 6.15pm Ward 5C



M edical history

k/c/o:DM (1 year),HPT (10 years),gout

July 2010 : duodenal ulcer& perinephric abcess fromHOSHAS

August : syncopal attack and hemetemesis/melena12 Sept (DOA) : 1. UGIB 2° duodenal ulcer

2. anemia 2° UGIB3. R perinephric abcess



C urrent condition

Melena°/hemetema°Stable & responsive to questionsProblem in memory (day/date)Not accompanied by caretaker but only available at 7pmeveryday

Non-ambulatory RT afraid of pain at PCD drainage site able toeat at semi recumbent position but limited ability to preparefoodPoor appetite RT pain & being selective on certain food RTaltered taste in agingGood dentition & have proper chewing ability



Perinephricabcess

UGIBDU

DM

anemic

Pain

fever Poor oralintake

Candida albicans in immune suppressed and diabetic patients are bacteria found in theabcess (Patterson JE & Andriole VT,1999)

R arely, perinephric abscess may be a presentation of infectious disorders of thegastrointestinal tract. Only two cases GI diorders (ruptured retrocecal appendix &chronic D U ) has been reported( Ching-Tien Kao et al,2002)

Involuntary wtloss

Poor NutritionalStatus

Imm uno-

comp ro m ised



N utritional Status Assessment

Usual BW is 106 .Loss 30 kg (> 10% of UBW). Indication for high risk of malnutrition.

Date Weight (kg) Height (cm) BMI(kg/m²)

IWR (18.5-24.9)

Wt history(kg)

22/9/10 61.3(unfit- IBW )

165(obtained from

patient)

22.5 50.4-67.8kg 6 y.ago-1063month ago- 76

Current-don t know but keep on loosing

Anthropometry

An unplanned wt loss of 10% or more is a risk factorfor malnutrition (Manual of Clinical Dietetics,5 th edition)



12.4 12.4 11 6.7 5.5 5.5

179

147 141

103 10390

Urea & Creatinine

D4 ORS introduced

Creatinine (59-104 mol/L)

Urea (2.5-6.4mmol/L)

Dehydration on DOAAEB ve fluid balancebut resolve now

Biochemistry

stopped



24

9.4 9.4 9.8 7.4 8.4

42.6

30 30 30 30 30

WBC and Globulin

WBC(4-10X 10 9/L)

Globulin (20-35 gm/L)

IV .Imipenem (anti bact)Infection on DOA(with high T°)but now resolve relatedto mx given



7.38.4 9.5

11.3

8.4 8.3 9.1

H bHb

Hb(13-17g/dL)

2 Platlet Count

T.pentoprazole(antiulcer)Persistent low Hb even undermx(PC& antiulcer) R T anemiccondition+poor intake



17.8 17.8

8.2

3

8.4 8

11.9

10

13

D extrose

Dxt (4-7.8 mmol/L)

Actrapid 2 UActrapid 4 U

Actrapid 3 U

Actrapid stat

Actrapid stopped

Persistently high Dxt evenunder insulin & OAD R Tstress condition



Test (Unit) Normal values* 12/9 Comments

L iver Test function

T.Protein (g/ L ) 66-83 68.2 Normal total

proteinAlbumin (g/ L ) 35-50 25.6 Low albumin

indication of malnutrition AE B wt loss >10% of usual BW +poorintake

T. B ilirubin ( mol/ L ) 0 - 20 19 Normal T. B ilirubin



C linicalVital Signs Normal Values 12/9/10 20/9/10

B P(mmHg) 130/80 120/80 130/80 Normal B P under mx

Temperature (ºC) 37 39 (t.sponging) 37 Fever resolve

I /O Positive balance -110 +550 I mproved into +vebalance

B /O 1x/d (normal to pt) B NO B NO for 8 days Symptom of constipation R T nomotility associated

with disease condition

spo2 100% 98 NP ( R T UGIB ) 99% R A I mproved respiration

Drug (f)

Metformin 500 mg B D OAD

T perindopril 8mg OD anti HPT

T amlodipine 10 mg OD anti HPT

IV imipenem 500 mg B D antibiotic

T pentoprazole 40 mg OD Antireflux/Alleviate ulcer



D ietary (hospital)

M eal time Food items Amt E (k C al) C HO (g) P (g) Fat (g)

BF (8am) Roti +kaya 2 pcs 157.5 37.5 4 6

+sweet coffee (1tbspsugar)

1cup 60 15 - -

L(12pm) White rice ½ exc 37.5 7.5 1 0.25

fish +vegetable soup 1exc 125 - 7 11

papaya 1 slice 60 15 - -

AT(4pm) Roti +kaya 2 pcs 157.5 37.5 4 6

Plain water 1 glass - - - -

Total 112.5 17 23.25

Total (kCal) 727.25 450 68 209.25

% 62 9.3 28.7



Nutrition Diagnosis

FFQ: no refine sugar /high salt routine but query on why food served hassugar (drinks/kaya). Alcohol °smoke°

No outside food takenPlain water 1.5 L /day taken

Poor appetite½ exc rice during lunch< ½ recommended energy meet by total oral intake

Selective towards H BV protein- Able to finish fish but not chicken since it isclaimed to be lembik . Prefer ayam kampungCan tolerate milk powder & egg.Adequate Fiber (vege& fruit) R T pt s preferenceFaulty believe- cannot take egg to prevent puss & did not take dinner sinceafraid of high blood glucose

Inadequate energy & protein intake R T decreasing appetite AE B Energy intake of 727.25 kcal/d & Protein intake of 17 g/d, less than requirement (energy req~1800(30 kcal/kg BW ) kcal/d & protein req ~67.4 g/d)



Medical Nutrition Therapy



Estimation of energy requirement

Harris-Benedict BEE= 66.47 + 13.75 (Wt) + 5 (Ht) 6.76 ( Age)= 66.47 + 13.75 (61.3) + 5 (165) 6.76 (62)

TEE = BEE x AF x IF AF= 1.1 (confine to bed) IF= 1.2 (mild stress RT high Dxt)

= 1315 x 1.1 x 1.2= 1736 kCal

Quick Method= 30 kCal/kg x IBW= 30 kCal/kg x 61.3 kg= 1839 kCal

RNIMale 60-65 y old= 2010 kcal/d

To plan for 1800 kCal/day menu

Estimation of protein requirement = 1.1-1.2 g/kg x IBW (mild stress RT low alb, poor appetite & drainage procedure)= 1.1-1.2 g/kg x 61.3 kg= 67.4 -73.6g/day

RNI=59 g/d

Intervention



Objective

To provide adequate energy & protein and preserve lean bodymassTo improve macronutrients and micronutrient biochemabnormalities (Dxt)To encourage better quality of life (BO) to promote bowelmotility

PrincipleBy providing high calorie high protein diet and top up withnourishing fluid with:E=1800 kcal/d protein:67.4- 73.6g/d (1.1-1.2g/kgBW)

fluid=1.8L/d (1kcal/ml)



Implementation1. Encourage orally as much as pt tolerated to meet Energy recommendation by

promoting small & frequent feeding

2. Correct on faulty believeHigh BG RT stress condition prolonged fasting (skip dinner) that lead torebounce hyperglycemiaPuss RT improper hygiene that lead to infection. Egg white is ok to take not yellowcoz yellow have sulphur(worsen the puss)

3. Explain on high protein dietNeed to increase H BV protein intake for early recovery+ boost immunity againstinfection

Encourage to finish fish/chicken(if fish is not possible)/egg provided (ratah lauk)Discuss with cook to provide fish only

4. Discuss regarding LSDD diet to pt and cooksuppose pt should not get kaya bun. Pt must report if order is not correct

5. G lucerna SR as oral supplement according to nurse shift (3 shifts/d).High protein,high calhave fiber for bowel openSR of glucose to alleviate stress induced hyperglycemia

6. Compliment good attitude & motivate changes

Cont current fluid intake for good hydration status & forBO

Motivate movement when there is no pain for bowel motility





M enu planningFULL HO S P ITAL M eal Energy C HO P Fat

BF ± 2pcs White B read + 1 nos egg + 2 tsp margerineL ± 4exc White rice+ 1 exc fried fish + 1exc fruitAT-2pcs White B read + 1 nos egg + 2 tsp margerine

D-4 exc White rice+ 1 exc fried fish + 1 exc fruit

215531215

531

307530

75

111511

15

151915

19Glucerna SR± 2 ½ scp (x3*/d) 278 36 13.5 9.8

Total : 1770 246 65.5 77.8

H ALF HO S P ITAL M eal Energy C HO P Fat

BF ±2pcs White B read + 1 nos egg + 2 tsp margerineL ±2 exc White rice+ ½ exc fried fish + 1exc fruitAT-2pcs White B read + 1 nos egg + 2 tsp margerineD- 2 exc White rice+ ½ exc fried fish + 1 exc fruit

215363215363

30453045

117.5117.5

15171517

Glucerna SR± 6 scps (x3*/d) 666 86.4 32.4 23.4

Total : 1822 236.4 69.4 87.4

LITTLE HO S P ITAL M eal Energy C HO P Fat

BF ±1pcs White B read + ½ nos egg + 2 tsp margerineL ±1 exc White rice+ ½ exc fried fish + 1exc fruitAT-1pcs White B read + ½ nos egg + 2 tsp margerineD- 1 exc White rice+ ½ exc fried fish + 1 exc fruit

185.5291185.5291

15301530

5.55.55.55.5

11.516.511.516.5

Glucerna SR± 6 scps (x4/d) 888 115.2 43.2 31.2

Total : 1841 205.2 65.2 87.4



Monitoring



B iochemical

28

30

Albumin progression



109

8 8

23-Sep 24-Sep 25-Sep 26-Sep

Dxt

Progression

Dxt ProgressionRelate to 2 HPP.did pt just take meals?2 hpp is 7-11



D ietary

Able to finish half of hospital diet Tolerate supplementation providedPt is taking dinner servedImproved appetite

Meal on 23 sep-5 oct 2010 Energy

C HO PFat

BF ±1pcs White B read + 1 nos egg + 2 tsp margerineL ±2 exc White rice+ 1 exc fried fish + 1exc fruitAT-1pcs White B read + 1 nos egg + 2 tsp margerineD- 2 exc White rice+ ½ exc fried chicken + 1 exc fruit

239377239381

15451515

1111117.5

15171519

Glucerna SR± 6 scps (x3*/d) 666 86.4 32.4 23.4

Total : 1902 176 73 89.4



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