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Case Report

Case Report. 中山醫學大學 實習生 李佳靜 指導老師 陳燕慈營養師. General data. Name: 黃 X 勝 Sex: 男 Age: 18 歲 3 個月 Admission date: 2012/3/21 Diagnosis: lung transplant , primary pulmonary hypertension. Brief history -He had congenital valve disease and primary

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Case Report

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  1. Case Report 中山醫學大學 實習生 李佳靜 指導老師 陳燕慈營養師

  2. General data • Name: 黃 X 勝 • Sex: 男 • Age: 18歲3個月 • Admission date:2012/3/21 • Diagnosis: lung transplant , primary pulmonary hypertension

  3. Brief history -He had congenital valve disease and primary pulmonary hypertension with severe right heart failure, diagnosed in 2002 and was under medical control for years. • Chief complaint -Informant : family -fever with intermittent dyspnea and cyanosis for one day

  4. 入院診斷 1. Primary pulmonary hypertension with severe right heart failure. 2. Pulmonary crisis 3. Perianal abscess

  5. history • 21 因呼吸困難、心悸入院 • 26Central ECMO set up 2012/3 體重下降至43kg(4/27) • 19Tracheostomy 2012/5 2012/6 • 1 建議嘗試water and soft diet • 4 GI bleeding • 8 NPO，數天後GI bleeding改善 • 提供一半牛奶+胃切diet • 12 照會RD PPN+佳易得1kcal/c.c(20c.c/hr) • 19Bilateral lung transplant • 21Decortication for blood clot removal • 24closure of the sternotomy wounds 2012/7 • 18 照會RD 倍力素*3+佳易得1500kcal=2400kcal 2012/8 • 29ECMO removal • 從2012/3月始，有PSVT、massive GI bleeding、hyperthyroidism • 因為長期臥床，有sacral pressure sore

  6. Nutrition Care

  7. SOAP 1 2012/9/19

  8. SOAP1 2012/9/19 • Subjective 母親敘述病人已經喝膩營養品 喜歡喝湯品，但一次攝取量不能太多 -飲食歷史: 醫院飲食: 早)地瓜粥1/2碗+配菜2~3口 午晚)白飯1碗+配菜2~3口+肉1~2小塊 其他自備: 豆漿200c.c、紅豆湯135g+120g、豆花320g、 雞湯100g、安素1罐

  9. SOAP1 2012/9/19 • Objective

  10. SOAP1 2012/9/19 • Objective • 依據ASPEN 2004 -Estimate energy needs = BEEx1.75=1210.29x 1.75=2118 Kcal/day 目標熱量:2100 kcal/day -Estimate protein needs =33.7x 2.5= 84.25 g/day 目標蛋白質量:90g/day

  11. SOAP12012/9/19 • Objective • 目前飲食 -Energy intake : 約1300~1400 kcal/day -Protein intake : 約60~65 g/day

  12. SOAP1 2012/9/19 • Assessment 1.體重過輕(Underweight) 2. 熱量攝取不足:60~67%目標熱量 3. 蛋白質攝取不足: 67~70%目標蛋白質量

  13. SOAP1 2012/9/19 • Plan 1.利用口服營養補充品搭配天然食物一起使用 例如:使用豆花(去糖水)+安素1/2瓶 2.以濃湯取代清湯 3.少量多餐，宜每2小時餵食1次 4. 建議可訂醫院飲食: 早晚小兒B餐+中午特甲飲食

  14. SOAP 2 2012/9/27

  15. SOAP 2 2012/9/27 • Subjective 病人主述最近胃口不錯，三餐可吃完1/2以上 病人主述喝膩營養補充品 -飲食歷史: 醫院飲食: 早)小兒B餐，吃1/2量 +自備豆漿170c.c 午)特甲飲食，吃1/2量 +自備豆漿260c.c 晚)小兒B餐，全吃完 +果汁牛奶110c.c+香蕉85g 自備: 午點)倍力素270c.c 晚點)拉麵0.5碗+花生豆花(去糖水)+牛奶140c.c +基速得1包 (開始做復健運動)

  16. SOAP 2 2012/9/27 • Objective

  17. SOAP 2 2012/9/27 • Objective • 目前飲食 -Energy intake : 約1750~1800 kcal/day -Protein intake : 約75~80 g/day

  18. SOAP 2 2012/9/27 • Assessment energy intake%:80~85%目標熱量 protein intake%:83~88%以上目標蛋白質量 • Plan 1.持續高蛋白高熱量飲食 早晚:小兒B餐 午:特甲飲食 2.嘗試不同口味營養品(ex.安素巧克力口味)

  19. SOAP 3 2012/10/12

  20. SOAP 3 2012/10/12 • Subjective 病人主述目前不喜歡吃稀飯 -飲食歷史: 醫院飲食: 三餐皆可吃2/3以上 早晚)小兒B餐 午)特甲飲食 自備: 午點)低脂牛奶300c.c 晚點)牛肉飯1碗+柳橙汁190c.c / 牛肉麵1碗 營養品:改使用益肺佳1瓶/天 or 倍力素1瓶/天

  21. SOAP 3 2012/10/12 • Objective

  22. SOAP 3 2012/10/12 • Objective • 目前飲食 -Energy intake : 約2100~2200 kcal/day -Protein intake : 約80~90 g/day

  23. SOAP 3 2012/10/12 • Assessment energy intake%:100%目標熱量 protein intake%:88~100%目標蛋白質 • Plan 1. 持續高熱量高蛋白飲食(早晚:小兒B餐、午:特甲飲食) 2. 小兒B餐早餐稀飯改成三明治與芋泥包配鹹粥

  24. Summary

  25. Summary

  26. Summary

  27. ~Thanks for your attention~

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