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Case Report

Case Report. 指導老師：蕭佩珍營養師 學生：張瀞文. Name: 郭○和 Gender: male Age: 66 y/0 Admission date: 2012/10/14 ~ Diagnosis : 1. Pneumonia 2. Diabetes mellitus 3. Chronic renal failure, end stage under hemodialysis 4. Hypertension. Marital status: married

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Case Report

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  1. Case Report 指導老師：蕭佩珍營養師 學生：張瀞文

  2. Name: 郭○和 • Gender: male • Age: 66 y/0 • Admission date: 2012/10/14 ~ • Diagnosis : 1. Pneumonia 2. Diabetes mellitus 3. Chronic renal failure, end stage under hemodialysis 4. Hypertension

  3. Marital status: married • Education: elementary school • Smoking: denied,已戒菸10年 • Drinking: denied • Betal nut chewing: denied • Occupation: retired • Psychological History and Evaluation 精神情緒狀態:異常 倦怠 焦慮 睡眠形態:異常 淺、易醒

  4. 2001 DM 2010 UGI bleeding , BUN/Cre elevated persistent renal insufficiency underwent left AV fistula creation Jan 2012 started hemodialysis July 2012 Went to ER for fever and cough with yellowish sputum Oct 2012 pneumonia Oct 17

  5. Nutrition consultation Diet control for HD

  6. 2012/10/17醫師照會營養師 • 照會主旨： For nutrition control and management

  7. Subjective:2012.10.17 • 1.Appetite: fair • 2.病人不太敢吃東西,怕洗腎前後體重差太多 3.Diet history: 早餐:LPF1杯(10平匙+250ml) 午餐:飯3份+菜0.5份+肉1份 晚餐:與午餐類似 4.水果：喜歡吃西瓜、香蕉(1根)

  8. Objective:2012.10.17 • BH=165cm, BW=56kg, BMI=20.6 IBW= 53.9～65.9Kg • Estimated Energy Requirement≒1800kcal/day Estimated Protein Requirement ≒70-75gm/day • Total calorie count ≒1200kcal/day • AC sugar：71 mg/dl • sugar(16:00)：368 mg/dl • Blood pressure：139/68 mmHg

  9. Lab data

  10. Medication:2012.10.17

  11. Assessment:2012.10.17 • 1.體位:合宜 • 2.熱量攝取不足 • 3.碳水化合物攝取量偏低 • 4.肉魚豆蛋類攝取量偏低 • 5.膳食纖維攝取量不足，蔬菜類攝取過少

  12. Plan:2012.10.17 衛教對象:病人本人與配偶 • 1.糖尿飲食衛教 • 2.血液透析飲食衛教 • 2.依建議熱量1800Kcal，定時定量 • 3.增加肉魚豆蛋類攝取：5~6份/天 • 4.增加蔬菜攝取：3份/天 • 5.低鉀水果衛教 • 6.磷結合劑正確使用方法 • 7.建議可訂醫院餐點

  13. Subjective:2012.10.19 1.Appetite: fair 2. Increase oral intake:50~60% 3. about the hospital diet : 早餐:白粥可全吃完+配菜大概吃一半 午餐:白飯吃完+青菜0.5ex+肉2ex+葡萄5粒 晚餐:白飯吃一半+青菜0.5ex 不喜歡晚餐的咖哩雞，無法接受咖哩味道 4.晚上有時睡得不好，一直咳。

  14. Objective:2012.10.19 • BW=57.5kg • Total calorie count ≒1400~1500kcal/day • ACsugar：98 mg/dl • sugar(17:21)：220 mg/dl • Blood pressure：155/78 mmHg

  15. Lab data

  16. Medication:2012.10.19

  17. Assessment:2012.10.19 • 1.體位=合宜 • 2.熱量攝取不足 • 3.肉魚豆蛋類攝取量不足(不足4~5份) • 5.蔬菜攝取量不足(不足2份) • 6.營養觀念不清楚

  18. Plan:2012.10.19 衛教對象:病人本人 • 1.鼓勵攝取全部餐點 • 2.複習血液透析飲食衛教 • 3.維持飲食醫囑+備註：忌咖哩

  19. Subjective:2012.10.20 • 1. Appetite: good • 2.Increase oral intake:70~80% • 3.醫院的供餐大約可吃7~8成 • 3.咳嗽情況有稍微改善 • 4.妻子詢問低鉀水果相關問題

  20. Objective:2012.10.20 • 10/19：BW=57.5kg • 10/20：BW=58kg →BW gain < 5% • Total calorie count ≒1600~1700kcal/day • ACsugar：81 mg/dl • sugar(17:12)：235 mg/dl • Blood pressure：137/65 mmHg

  21. Lab data

  22. Medication:2012.10.20

  23. Assessment:2012.10.20 • 1.體位=合宜 • 2.熱量攝取增加 • 3.肉魚豆蛋類攝取量增加(2份→4份) • 4.青菜攝取量增加(1份→1.5份) • 5.營養觀念：改善 • 6.飲食遵從度：可

  24. Plan:2012.10.20 衛教對象:病人本人及配偶 • 1.鼓勵攝取全部餐點 • 2.維持醫院飲食醫囑 • 3.低鉀水果衛教複習

  25. Subjective:2012.10.22 • 1.appetite：well • 2. Increase oral intake:80~90% • 3.今日出院，心情佳 • 4. 妻子描述： 昨天醫院的供餐，幾乎都有吃完。

  26. Objective:2012.10.22 • BW=57.4kg • Total calorie count ≒1750~1800kcal/day • AC sugar：89 mg/dl • Blood pressure：140/77 mm/Hg

  27. Lab data

  28. Medication:2012.10.22

  29. Assessment:2012.10.22 • 1.體位=合宜 • 2.熱量攝取尚可 • 3.肉魚豆蛋類攝取量增加(4→5份) • 3.青菜攝取量增加(1.5份→3份) • 4.飲食遵從度：佳

  30. Plan:2012.10.22 衛教對象:病人本人及配偶 • 1.鼓勵出院後，維持良好飲食習慣 • 2.鼓勵出院後，執行每日自我血糖監控

  31. Summary • 透過四次追蹤→營養知識與觀念進步

  32. 熱量攝取增加 目標值

  33. 蛋白質攝取量增加 目標值

  34. Thank you Very much

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