A Case Study of a 5-Month Old Male Infant

with Complete Intestinal Obstruction secondary to Incarcerated

Indirect Inguinal Hernia1

Carmina delas Alas

Marfil Mantica

Jacelyn Salvamante

Lara Jane Sarbues

Lauren Rose Tamondong

HNF 41 T-1L

____________________
1
A case study in partial fulfillment of the requirements in HNF 41, Diet Therapy I during the 2 nd
semester 2009-2010 under the supervision of Ms. Lowela Padilla, UPLB, CHE, IHNF.
I. Introduction

a. Concepts in Nutrition, Diet Therapy, and Organ System Concerned

A person’s health is affected by food intake because these are the objects that can be

taken to the body to yield energy and nutrients for the maintenance of life and the growth and

repair of the tissues (Whitney, 2005). Nutrition is the science of food, the nutrients and other

substances therein, their action, interaction and balance in relation to health and disease, and the

process which the organism ingests, digests, absorbs, transports, utilizes and excretes food

substances (Lagua and Claudio, 2004).

The nourishment process is primarily attributed to digestion and absorption. Digestion is

the body’s ingenious way of breaking down of foods into small units of nutrients in preparation

for absorption (Whitney, 2005). This process is done by the Digestive system. It is comprised

mainly by the mouth, pharynx, epiglottis, esophagus, esophageal sphincter, stomach, pyloric

sphincter, gallbladder, pancreas, small intestine, ileocecal valve, large intestine, appendix,

rectum, and anus. The principal functions of the gastrointestinal tract(GI) are the extraction of

macronutrients, proteins, carbohydrates lipids, water, and ethanol from ingested foods and

beverages, absorbance of crucial micronutrients and trace elements and serves as a physical and

immunologic barrier to microorganisms, foreign material and potential antigens consumed with

food or formed during the passage of food (Mahan and Escott-Stump, 2004).

The human GI tract could digest and absorb 92% to 97% of the foods being ingested

(Mahan and Escott-Stump, 2004). This study focuses on the small intestine. Principally, it is the

site of digestion and absorption for numerous nutrients. It is divided into three parts: duodenum,

jejunum, and ileum. The duodenum is about 0.5 meters long, the jejunum is 2 to 3 meters long

and the ileum is 3 to 4 meters long. The nutrients and minerals that are absorbed in this site are
Chloride, Sulfate, Iron, Calcium, Magnesium, Zinc, Glucose, Galactose, Fructose, Vitamin C,

Thiamin, Riboflavin, Pyridoxine, Folic Acid, Amino Acids, Dipeptides, Tripeptides, Vitamins A,

D, E, K, Fats, Cholesterols, Bile Salts, and Vitamin B12 (Mahan and Escott-Stump, 2004).

Some of the common intestinal problems and diseases are Intestinal Gas and Flatulence,

Constipation, Diarrhea, Steatorrhea, Gastrointestinal Strictures and Obstruction, Celiac Disease,

Tropical Sprue and Hernias. The case study is about Hernia and Complete Intestinal Obstruction.

Hernia is the protrusion of an organ or tissue out of the body cavity in which it normally

lies (Martin, 2000). There are two common types of hernia – Hiatal and Inguinal. This study

focused on Inguinal Hernia. Inguinal Hernia occurs when a section of the small intestine

protrudes through abdominal muscles, causing a lump in the groin. In men, the hernia often

protrudes into the scrotum, the sac that holds the testes. An inguinal hernia usually results from

weak abdominal muscles and increased pressure in the abdomen. This combination forces a loop

of intestine out through the weak area in the muscle wall. Obesity, heavy lifting, and prolonged

coughing can cause a hernia or make it worse (California Teachers Association, 2002). There are

two types of Inguinal Hernia – Incarcerated and Strangulated. And as a diagnosis, the patient has

experienced an Indirect Incarcerated Inguinal Hernia. It is congenital and common to males than

in females because of the way males develop in the womb (National Institute of Diabetes and

Digestive and Kidney Diseases, 2010). Incarcerated Hernia can lead to a Strangulated Hernia in

which the blood supply to the incarcerated small intestine is put at risk (National National

Institute of Diabetes and Digestive and Kidney Diseases, 2010).

One of the complications of Indirect Incarcerated Inguinal Hernia is Intestinal

Obstruction. It results when the lumen is occluded at two points by single mechanism such as a

hernia ring or adhesive band, thus producing a closed loop wherein the blood supply is often

obstructed by the same time (Harrison, 2001).

 Upon the recurrence of these digestive problems, the role of diet therapy comes in. Diet

Therapy is the branch of dietetics that is concerned with the use of food to maintain good

nutritional status, correct deficiencies that may have occurred, afford rest to the whole body or to

certain organs that may be affected by disease, adjust the food intake to the body’s ability to

metabolize the nutrients and bring about changes in body weight whenever necessary (Lagua and

Claudio, 2004).

b. Importance/Significance of the Study

The diagnosed disease of the case patient could have noteworthy effects on the nutritional

status and consequent metabolic processes. Intestinal Obstruction and Incarcerated Inguinal

Hernia could cause inauspicious effects on the nutritional and health status of the patient. If this

diagnosed aberration is not treated appropriately, it could result to anatomic and physiologic

damages, and in due course, may put the subject’s life at risk.

This study might also be accounted to be significant for it might provide crucial

information on the grounds of the above-stated disorders. Moreover, the assessment of the case

patient’s status might provide necessary data for further studies regarding the same disorder.

Lastly, this study would promote advocacy on the nutritional and health welfare of the case

patient and all concerned individuals.

 c. Objectives of the Study

The general objectives of the study are to explain the condition of the patient on having

Intestinal Obstruction Secondary Indirect Incarcerated Inguinal Hernia and to provide a

Nutritional Care Plan for the alleviation of the patient’s condition.

The specific objectives of the study are to:

• describe the disorder condition of Incarcerated Inguinal Hernia and its relation to

Intestinal Obstruction;

• interpret and analyze the biochemical test results of the patient to identify the causative

factors for the abovementioned disorders, if there is any;

• examine the effects of prescribed drugs on the patient’s nutritional and health status;

• assess the nutritional status and food intake nutrient adequacy of the patient using dietary

history such as the 24-hour food recall and anthropometric measurements such as weight,

height, etc., both for prior to admission and during hospitalization;

• prepare an individualized and simplified therapeutic diet for the patient that would

improve the current nutritional and health status; and,

• provide a Nutrition Care Plan for the patient that would include appropriate suggested

recommendations and specified nutritional interventions.

d. Limitations of the Study

The study was conducted with the available primary and secondary data obtained

from the hospital and the interview with the patient’s relatives. These only support the

credibility of the study. The following are the limitations of the study:
 • the interview with the patient’s relatives was only based on their own

understanding from their observation on the patient’s condition;

• The medications that were given to the patient are fully generic. The brand

names were not specified. Thus, some of the possible nutrient and drug

interactions cannot be determined specifically;

• The dietary information was not completely stated in the medical record

because the amount of the food and the frequency of feeding are not all

specified.

• An interview with the attending physician and nurse was not conducted.

Hence, additional information was not gathered;

• The researchers are not technically inclined with medical knowledge;

• The study has only focused on the intestinal obstruction and incarcerated

inguinal hernia. Other complications out of the topic would not be fully

discussed in the study;

• The anthropometric data obtained are incomplete because the medical record

has only provided the weight of the patient.

II. Methodology

A request letter about the case patient with metabolic and gastrointestinal disorders was

provided by the HNF41 Faculty. It was submitted to the “Ospital ng Muntinlupa”. The letter has been

received on February 18, 2010 in the Hospital Director’s office. The researchers were referred to the

Nursing Department to be facilitated on the records of the admitted patients. The medical record of
the patient has been copied and an interview with the patient followed. The gathered data which

includes personal data, nutritional and dietary history, and other supporting documents, were

analyzed and assessed, and recommendations were suggested to the case patient.

III. Theoretical Consideration

1. Incarcerated Inguinal Hernia

A. Disease condition

An Inguinal hernia occurs when soft tissue — usually part of the intestine — protrudes

through a weak point or tear in the lower abdominal wall which results to a lump that can be

painful especially when a person cough, bend over or lift heavy object. When this happens, the

blood supply to the intestine is reduced, and the intestinal tissue starts to die.

An incarcerated indirect inguinal hernia is a condition wherein the hernia becomes stuck

in the groin or scrotum that cannot be put back to the abdomen. A part of the intestines protrudes

through an opening in the lower part of the abdomen, near the groin, called the inguinal canal. It

results from the failure of embryonic closure of the internal inguinal ring after the testicle has

passed through it. An inguinal hernia appears as a bulge on one or both sides of the groin. It may

occur any time from infancy to adulthood and is much more common in males than females. And

it may tend to become larger in time.

B. Classification/types
 Unlike inguinal hernia which occurs when a section of the small intestines protrudes to the

stomach muscles, Hiatal hernia occurs when there is a protrusion of a stomach part in the muscle

wall that separates the chest cavity from the abdominal cavity. This protrusion allows the stomach

contents to flow backward into the esophagus (The Carewise Guide, 1996).

An incarcerated inguinal hernia is caused by swelling and can lead to strangulated hernia,

causing the blood supply to the incarcerated small intestine to be jeopardized. A strangulated

hernia is a serious condition and requires immediate medical attention or surgery.

Direct and indirect hernias are the two types of inguinal hernia, and they have different

causes.

Indirect inguinal hernias, which are congenital hernias, are more common in males than

females because of the way males develop in the womb. In the male fetus, the spermatic cord and

both testicles—starting from an intra-abdominal location—normally descend through the inguinal

canal into the scrotum. Sometimes the entrance of the inguinal canal at the inguinal ring does not

close as it should just after birth, leaving a weakness in the abdominal wall. Fat or part of the

small intestine slides through the weakness into the inguinal canal, causing a hernia. In females,

an indirect inguinal hernia is caused by the female organs or the small intestine sliding into the

groin through a weakness in the abdominal wall (National Institute of Diabetes and Digestive and

Kidney Diseases, 2010). Indirect hernias are the most common type of inguinal hernia. Premature

infants are especially at risk for indirect inguinal hernias because there is less time for the

inguinal canal to close (National Institute of Diabetes and Digestive and Kidney Diseases, 2010).

Direct inguinal hernias are caused by connective tissue degeneration of the abdominal

muscles, which causes weakening of the muscles during the adult years. Direct inguinal hernias

occur usually in males. The hernia involves fat or the small intestine sliding through the weak

muscles into the groin. A direct hernia develops gradually because of continuous stress on the
muscles. One or more of the following factors can cause pressure on the abdominal muscles and

may worsen the hernia:

• sudden twists, pulls, or muscle strains

• lifting heavy objects

• straining on the toilet because of constipation

• weight gain

• chronic coughing

Indirect and direct inguinal hernias usually slide back and forth spontaneously through

the inguinal canal and can often be moved back into the abdomen with gentle massage (National

Institute of Diabetes and Digestive and Kidney Diseases, 2010).

C. Etiology

It might take a long time for a hernia to develop or it might develop suddenly. Many

Inguinal hernias occur as a result from the increased pressure in the abdominal wall, a pre-

existing weak spot in the abdominal wall or the combination of the two. Hernias may cause by a

combination of muscle weakness and strain, although the cause of the weakness and the type of

strain may vary. In these cases, straining the muscles does not cause the hernia but rather makes

the hernia more apparent. Some types of the strain on the body that may induce hernias are:

• Obesity or sudden weight gain

• Lifting heavy objects

• Diarrhea or constipation

• Persistent coughing or sneezing

 • Pregnancy

Also, it usually occurs at birth when the abdominal lining or the peritoneum does not

close properly. Other Inguinal hernia develops through time when muscles deteriorate due to

factors such as aging, strenuous physical activity or coughing that accompanies smoking (Mayo

Clinic, 2010).

D. Incidence

Hernias are actually more common in babies and toddlers. And most teenagers who are

diagnosed with a hernia actually have had a weakness of the muscles or other abdominal tissues

from birth (called a congenital defect).

About five in every 100 children have inguinal hernias. Nearly 10 times more men than

women have inguinal hernias, and the vast majority of inguinal hernias are among boys (Mayo

Clinic, 2010).

E. Pathophysiology
 A hernia occurs when intra-abdominal contents traverse the ring to enter the inguinal

canal. As time passes, the hernia contents may enlarge, extend the length of the canal, and even

exit the canal through the external inguinal ring, an opening in the external oblique fascia, into

the scrotum (Mayo Clinic & Free MD, 2010).

Men are more likely to have an inherent weakness along the inguinal canal because of the

way males develop in the womb. In the male fetus, the testicles form within the abdomen and

then move down the inguinal canal into the scrotum. Shortly after birth, the inguinal canal closes

almost completely, leaving just enough room for the spermatic cord to pass through, but not large

enough to allow the testicles to move back into the abdomen (Mayo Clinic, 2010).

F. Clinical Manifestations and Underlying Mechanism

Clinical manifestations are pain and discomfort in the groin especially when bending or

lifting, a heavy and dragging sensation in the groin, and pain and swelling in the scrotum around

the testicles when the protruding intestine descends into the scrotum which happens in men

(Mayo Clinic, 2010).

2. Intestinal Obstruction

A. Disease condition

Intestinal obstruction is the blockage of the small intestine or colon that prevents food

and fluid from passing through it. The abnormal consequence of the obstruction depends on the

part in the gastrointestinal tract that becomes obstructed. If the obstruction occurs at the pylorus,
then persistent vomiting of the stomach contents occurs. If obstruction is beyond the stomach

intestinal juices are vomited along with the stomach secretions (Mayo Clinic, 2010).

B. Classification/Type

Intestinal obstruction may be mechanical which is caused by intestinal adhesions,

hernias, tumors, twisting of the intestine, narrowing of the outlet from the stomach and

inflammation or scarring from Crohn’s disease. It may also be non-mechanical which is caused

by chemical, bacterial and circulatory diseases (Fishbein, 1977).

C. Etiology

Clinically, it is more useful to consider whether the obstructive mechanism involves the

small or large intestine because the causes are different (Harrison, 2001).

Mechanical obstruction in the small intestine can be caused by intestinal adhesions,

hernias, tumors, twisting of the intestine, narrowing of the outlet from the stomach and

inflammation or scarring from Crohn’s disease. Adhesions and external hernias are the most

common causes of the obstruction of the small intestine, constituting 70 to 75% of cases of this

type (Harrison, 2001).

Mechanical obstruction of the colon can be caused by cancer, diverticulitis, twisting of

the colon, narrowing of the colon and paralytic ileum. The most common causes of the
obstruction of the colon which account 90% of the cases are carcinoma, sigmoid diverticulitis and

volvulus (Harrison, 2001).

The causes of non-mechanical intestinal obstruction are chemical, bacterial and

circulatory (Fishbein, 1977).

D. Incidence

Obstructions that are common in newborns and young children, especially in boys, are

the result of a twisting of the intestine that occurs when an inguinal hernia becomes incarcerated

(Fishbein, 1977).

E. Pathophysiology

Distention of the intestine is caused by the accumulation of gas and fluid proximal to and

within the obstructed segment. The accumulation of fluid proximal to the obstructing mechanisms

result not only from ingested fluid, swallowed saliva, gastric juice, and biliary and pancreatic

secretions but also from interference with normal sodium and water transport. After 24 hours of

obstruction, there is movement of sodium and water into the lumen, contributing to the distention

and fluid losses. Intraluminal pressure increases. Closed-loop obstruction of the small intestine

results when the lumen is occluded at two points by a single mechanism such as hernia ring or

adhesive band, thus producing a closed loop whose blood supply is often obstructed at the same

time. A form of closed-loop obstruction is encountered when complete obstruction of the colon

exists (Harrison, 2001).

 F. Clinical manifestation and underlying mechanism

Clinical manifestations of Intestinal obstruction are abdominal pain and swelling, nausea,

vomiting and diarrhea, swelling of the abdomen, abdominal tenderness (Mayo Clinic, 2010).

Distention of the abdomen and a bloated feeling occur because of a dilated intestine with a

complete obstruction (Fishbein, 1977).

IV. The Patient – General Information

a. Personal Data

The patient is Matt Joven Cajipe, a 7-months old infant. He was born on September

20, 2009 at their house located at Trece Martirez, Cavite. His parents are Jonathan and Mary

Jane Cajipe.

The 21-year old father works as a farm caretaker at Batangas and earns 1000 pesos in

a week. He is a smoker with a family history of Cardiovascular Diseases.

On the other hand, the 18-year old mother is a plain housewife who takes care of two

children – Matt Joven, the case patient and Mary Joyce who is two years in age. Their

residence house was provided by the owner of the farm where the father is working. The

Cajipe Family is Roman Catholic, a religion with few religion taboos.

b. Physician’s Diagnosis/Impession
 The patient was diagnosed with Complete Intestinal Obstruction secondary to Indirect

Incarcerated Inguinal Hernia.

c. Medical History

1. Chief complaint

The patient was brought to the hospital because he has experienced

difficulty in breathing.

2. History of the present illness

According to the hospital’s medical record, the patient started to have

productive cough and difficulty of breathing with fever two days prior to

admission. Also, he had poor appetite and did not drink milk

3. History of other illness in the past

The patient was diagnosed to have a congenital heart disease. It was

brought by his father’s family history of having this disease. Other than that,

there was no disease acquired by the patient.

 4. Family history

The patient has a congenital heart disease inherited from the family

side of his father.

5. Personal and social history

The patient lives with his family since birth. He might be exposed to

passive smoking because of his father’s vice.

d. Nutritional and Dietary History

The patient was admitted with a weight of 3.2 kilograms. He was admitted on

January 21, 2010. In January 27, 2010, the weight of the patient was 3.67 kilograms. He

gained 0.47 kilogram within a week prior to confinement in the hospital. Patient’s weight

on February 24, 2010 was 4.9 kilograms. Patient gained 1.7 kilograms relative to his

weight when he was confined.

 The infant was breastfed for only one week. The mother of the patient said that

her production of milk was stopped that is why she did not give her child breastmilk.

Then, the infant was given milk formula. The brand of milk formula that they were using

is Nestogen. The infant is also given water after taking the formula milk. The brand of the

formula milk that they were using was changed. Bona substituted Nestogen as prescribed

by the doctor. However, the infant took lesser amount. When the patient was five months

old, he was given solid food by her mother. The patient eats Marie biscuit. He consumes

one pack a day.

The infant is fed 6 times a day equivalent to 6 bottles of formula milk which

contains 3 scoops of milk and 180ml of water.

V. Treatment/Modifications

a. Dietary Intervention

The infant is given milk formula. The brand of milk formula that they were using

is Nestogen. According to the mother, the child is breastfed every three hours. There is no

definite amount of milk given to the child. The infant takes the milk formula in any

amount as tolerated. The infant is also given water, about 20-30ml, after taking the

formula milk. The brand of the formula milk that they were using was changed when he

was confined in the hospital. Nestogen was substituted by Bona as prescribed by the

doctor. There was no information gathered regarding the reason why the doctor

prescribed such brand of formula milk. However, the infant took the new brand of

formula milk for three days only. Usually the patient takes the formula milk six times a

day during his confinement in the hospital. However, the infant took lesser amount. The
patient is used to taking Nestogen as formula milk. The attending physician ordered to

shift to Nestogen again.

When the patient was five months old, he was given solid food by her mother.

The patient eats Marie biscuit. He consumes one pack a day. Until now the patient eats

the biscuit.

The patient was also given Parenteral nutrition to meet his body needs for

nutrients. This is essential since he undergone a major surgery and he has poor appetite.
 B. Medical Intervention

1. Drugs Prescribed or Given

The management of many diseases requires drug therapy, frequently involving the use of multiple drugs (Krause, 2006). The patient
underwent several medical procedures while in the hospital. Certain drugs were given to the patient to alleviate his condition (Table1).

Table 1.Drug Information prescribed to the patient.

Medication Generic Brand Indication Contraindication Adverse Reaction Administration Nutrient-Drug

Name Name Interactions
Ampicillin Ampicillin MAY Infections caused by Hypersensitivity to GI disturbances, Adult 500 mg 6 Ampicillin may
ampicillin susceptible gm-ve & penicillins, skin rashes, hrly IV or IM. hinder the
gm+ve bacteria infectious pruritus, urticaria, Severe infections production of B
mononucleosis fever, anaphylaxis, 150 mg/kg daily IV vitamins and
blood disorders, in equally divided vitamin K.
super infections. doses every 3-4
hours. Children
25-50 mg/kg daily
6 hrly IV/IM.
Severe infections
100-200 mg.kg
daily given in
divided doses every
3-4 hours starting
with IV for 3 days
then continue IM
for the remaining
days.
Captopril Captopril Not It is used to treat high Kidney disease (if Fainting, urinating For patients with Captopril
indicated blood pressure on dialysis), liver more or less than either normal or
(hypertension), disease, heart usual or not at all, low blood pressure
 congestive heart disease or fever, chills, body who have been
failure, kidney congestive heart aches, flu vigorously treated
problems caused by failure; diabetes; or symptoms; pale with diuretics and
diabetes, and to a connective tissue skin, easy bruising who may be
improve survival such as marfan or bleeding, fast hyponatremic
after a heart attack. syndrome, Sjogren’s pounding or and/or
syndrome, lupus, uneven heartbeats; hypovolemic, a
scleroderma, or chest pain, or starting dose of
rheumatoid arthritis. swelling , rapid 6.25 or 12.5 mg 3
weight gain. times a day may
minimize the
magnitude duration
of the hypotensive
effect for these
patient. Titration to
the usual daily
dosage can then
occur within the
next several days.

Heart Failure
initially 6.25 mg tid
& gradually
increase up to 59
mg tid.
Co-amoxiclav Co-amoxiclav Augmentin Prophylaxis against Hypersensitivity to Erythematous Augmentin may be Augmentin may
infections associated penicilllins. rash. Diarrhea, administered either hinder the
with major surgical Contagious pseudo by IV injection or production of B
procedures. mononucleoisis. membranous by intermittent vitamins and
Treatment of resp Penicillin associated colitis, indigenous, fusion. It is not vitamin K in the
tract, GUT, skin & jaundice or hepatic nausea, vomiting, suitable for IM intestine.
soft tissues, O &G dysfunction. stomatitis & administration.
infections. candidiasis. Children 3 months
Erythema -12yrs : usually 1.2
multiforme & g 8 hourly. In more
other skin effects. serious infections,
 Hepatic, increase frequency
hematological and to 6 hourly
renal effects. intervals; 0-
3months: 30 mg/kg
Augmentin every
12 hrs In premature
infants and full
term infants during
the prenatal period,
increasing to 8
hours thereafter.
Furosemide Furosemide Lasix Edema due to Anuria, hepatic Symptomatic Furosemide may be Nutrients affected
cardiac, hepatic & coma, & precoma; hypotension, administered IV or by drug: Calcium, ,
renal disease, burns; severe dehydration, Oral. Licorice,
mild to moderate hypokalamia&/or hemoconcentratio Magnesium,
hypertension, hyponatremia; n; hypokalemia, Tab adult initially Melatonin,
hypertensive crisis, hypovolemia w/ or hyponatremia, ½ -1-2 tab daily. Potassium, Sodium
acute heart failure, w/out hypotension. metabolic Maintenance: 1/2- 1 Vitamin B1,
chronic renal failure, Hypersensitivity to acidosis; increase tab daily. Vitamin B6,
nephritic syndrome. furosemide or of blood lipid Chldn2mg/kg body Vitamin C, Zinc.
sulfonamides. levels, urea, uric wt up to amax of 40
acid; reduced mg daily. Inj adult
glucose tolerance; initially 20-40 mg
hearing disorders, IV/IM. If diuretic
tinnitus; effect is not
pancreatitis, GI satisfactory dieresis
symptoms; is obtained, the
anaphylactic & dose should then be
anaphylactoid given once-bid.
reactions,
cutaneous
reactions; fever,
vasculitis,
interstitial
nephritis,
hemolytic or
 aplastic anemia,
leukocytopenia,
agranulocytosis,
thrombocytopenia,
paraesthesia,
photosensitivity,
nephrolithiasis,
nephrocalcinosis,
& increased risk
of persisitence of
Botallo’s duct if
used in premature
infant.
Gentamicin Gentamicin Garamicin Septicemia and Hypersensitivity Ototoxicity and Adult 3-5 mg/kg. Nutrients affected
serious infections of nephrotoxicity. body wt. older by drug are: Vit. B6,
the CNS, respiratory neonate & Calcium,
tract, GIT, skin and children 2 mg/kg 8 Magnesium,
soft tissues. hrly. Chronic Potassium.
recurrent UTI 160
mg once daily. IM
for 7-10 days.
Lanoxin Lanoxin Not Cardiac Failure Intermittent Nausea, vomiting, Lanoxin should be May deplete
indicated accompanied by atrial complete heart block anorexia, diarrhea, taken by oral thiamine with long
fibrillation; or 2nd degree AV gynecomastia, formulation or term use.
management of block esp if there is headache, through IV
chronic cardiac a history of Stokes- weakness, apathy, formulation. Using natural
failure where systolic Addam attacks; malaise, fatigue, Oral Adult& licorice product
dysfunction or arrhythmia caused depression, children > 10 yr may cause low
ventricular dilation is by cardiac glycoside psychosis, visual rapid oral loading levels of potassium.
dominant; intoxication, supra- disturbance, dose 750-1500mcg
management of ventricular ventricular as a single dose.
certain supra- arrhythmia caused premature Slow oral loading
ventricular by Wolff-Parkinson- contractions atrial dose 250-750 mcg
arrhythmias, White syndrome; or ventricular daily for 1 week
particulary atrial ventricular arrhythmias & followed by an
flutter and tachycardia or conduction appropriate
fibrillation. fibrillation; effects, Intestinal maintenance dose.
hypertrophic ischemia. Rarely Maintenance dose:
obstructive skin rashes and usually 125-750
cardiomyopathy. thrombocytopenia. mcg/day or ≤ 62.5
Hypersensitivity to mcg/day may
other digitalis suffice. Oral
glycosides. loading dose 5-10
years 25 mcg/kg. 2-
5 yr 35 mcg/kg.
Term neonates 2yr
old 4 mcg/kg, pre-
term neonates 1.5
kg-2.5 kg 30
mcg/kg 2-5yr 35
mcg/kg pre-term
nenonates <1.5 kg
25 mcg/kg. doses
taken per 24hr. inj
500-1000 mcg
loading dose,
depending on age,
lean body weight
and renal function.
IV loading dose
children 5-10yr 25
mcg/kg, 2-5yr 35
mcg/kg, term
neonates 2-yr 35
mcg/kg, pre-term
neonates 1.5-2.5 kg
30 mcg/kg,
preterm neonates
< 1.5 kg 20 mcg/kg.
doses taken over 24
hr. loading doses
administered in
 divided doses with
½ the total dose
given as the first
dose & the
remainder given at
4-8 hrly intervals,
assessing clinical
response before
giving each
additional dose.
Metronidazole Metronidazole Rodazid Treatment of Blood dyscrasia & GI discomfort, Anaerobic Not specified
Pharma susceptible protozoal active CNS disorder. anorexia infection &
nutria infections and in the Alcohol surgical chemo
treatment of prophylaxis
prophylaxis of 20-30mg/kg per
anaerobic bacterial day
infections.
Nalbuphine Nalbuphine Nubaine Used for control of Sedation, sweaty, Nubaine may be Not specified
moderate to severe clammy, nausea administered SC,
pain and as an and vomiting, IM or IV. The
adjunct to anesth. dizziness, vertigo, doses may be
dry mouth and repeated every 3-6
headache. hrs or as needed.
Adult 70 kg body
wt 10 mg S/MC/IV
repeated 3-6 hrly.
Non tolerant
individuals single
max dose 20 mg,
max total daily dose
160 mg induction
of anesth 0,3-3
mg/kg IV over 10-
15 min maintenance
dose: .25-.5 mg/kg
in single IV.
Paracetamol Paracetamol Tempra Mild to moderate Renal or hepatic Nausea, allergic May be taken with Not specified
pain and fever impairment; alcohol- reactions, skin or without food.
dependent patients; rashes, acute renal PO/Rectal 0.5-1 g
G6PD deficiency. tubular necrosis. 4-6 hrly when
Potentially Fatal: needed. Max: 4
Very rare, blood g/day. IV >50 kg: 1
dyscrasias (e.g. g 4-6 hrly (Max: 4
thrombocytopenia, g/day); <50 kg: 15
leucopenia, mg/kg 4-6 hrly
neutropenia, (Max: 60
agranulocytosis); mg/kg/day)
liver damage
Ranitidine Ranitidine Pharex Active duodenal Headache, Active duodenal Nutrients affected
Ranitidine ulcer, benign gastric sometimes severe, ulcer, active benign by drug: Folic Acid,
ulcer, pathological rarely dizziness, gastric ulcer 150 Iron, Vitamin B12.
hypersecretory insomnia, mgbid or 300mg
conditions, GERD, reversible mental once daily at
Erosive esophagitis, confusion, bedtime for 4
reversible blurred weeks.
vision, Maintenance
arrhythmias, therapy: 150mg/kg
constipation, at bedtime.
diarrhea, nausea,
vomiting,
arthralgias,
myalgias.
Salbutamol Salbutamol Ventar Relief bronchospasm Thyrotoxicosis, Fine tremor of Adult 200-400 mg May induce
in brochial asthma, cardiac arrhythmias, skeletal muscle 12 hrly. Children hypokalemia.
chronic bronchitis, coronary particularly the 100-200 mg 12
bronchiectasis, insufficiency, hands, nausea, hrly.
emphysema and other hypertension, pounding
reversible obstructive ischematic heart heartbeat,
pulmonary diseases. disease. Diabetis nervousness or
mellitus, restlessness.
hyperthyroidism,
ketoacidosis,
 pheochromocytoma,
sensitivity to
symphatomimetics,
ist trimester of
pregnancy.
Sources: MIMS Annual Philippines.2002. MediMedia: Singapore., MIMS Philippines 103rd edition. 2005. Wong Mei Chan: Singapore. ,
Integrative Medical Arts Group Inc. IBISmedical.com. Copyright ©1998-2000, Naturalnews.com
 2. Medical Treatment and Procedures (e.g. dialysis, insulin)

The patient has also undergone medical surgery. He has undergone

herniotomy to address the problem of hernia.

VI. Results and Evaluation

a. Disease Condition

Intestinal obstruction is a blockage of the small intestine or colon that prevents

passing of food and fluids. It can be caused by many conditions, with the patient it

was caused by hernia. Incarcerated inguinal hernia causes the obstruction of the small

intestine of the infant. Hernia is a mechanical obstruction that physically blocks the

intestine. Inguinal hernia occurs when soft tissue, usually the intestine, protrudes

through a weak point in the lower abdominal wall. (Mayo Clinic, 2010)

Inguinal hernia developed when the testicle of the male infant move down

into the scrotum through the inguinal canal. The canal closes after the baby is born to

prevent the testicles from moving back into the abdomen. However, this area does

not close off completely. A loop of intestine can move into the inguinal canal through

the weakened area of the lower abdomen which causes the hernia (Mayo Clinic,

2010).

b. Anthropometric Results

Data about the weight of the infant upon admission and confinement are the

only info obtained about anthropometric data. In determining the nutritional status of

the patient, weight-for-age nutrition index of IRS was used. The patient was admitted

with a weight of 3.2 kilograms. Nutritional status of the infant upon admission was
 below normal using the nutrition index of IRS which is weight-for-age. Patient’s

weight on February 24, 2010 was 4.9 kilograms. Nutritional status of the infant after

one month of confinement was also below normal using the nutrition index of IRS

which is weight-for-age. There was no length of the patient indicated.

Weight-for-age is useful in determining a rough estimate of present

nutritional status. However, using this nutrition index has limitations. One of the

limitations is it does not distinguish between acute and chronic malnutrition. Another

limitation is the interpretation may be complicated by the incidence of edema.

Possible systematic error may occur when inaccurate information gotten from

incorrect age (IRS, 1978).

c. Nutrient-Drug Interaction

Medication can affect with the nutrient absorption. Medication can reduce or improve

nutrient absorption. On the other hand, it can also affect nutrient metabolism (Cataldo, 2002).

The following medication, with its nutrient interaction, was taken by the patient during his

confinement in the hospital.

Gentamicin

Gentamicin is known to affect certain vitamins, Vitamins B6 (pyridoxine), Calcium,

Magnesium and Potassium.

Research reported that the use of gentamicin can interfere with Vitamin B6 metabolism,

but Vitamin B6 supplementation can alter the effect of it without reducing the drug’s efficacy.

Also it is reported that gentamicin can cause urinary calcium, magnesium and potassium loss

and kidney damage (www.IBISmedical.com). Though there are reported interference of the

drug with Vitamin B6 metabolism, the patient was not given a Vitamin B6 supplement.
Furosemide

The drug may decrease appetite thus decreasing nutrient intake. This drug is diuretic and

is known to deplete potassium and the depletion may also affect the magnesium levels. Other

nutrients affected by drug: Calcium, Licorice, , Melatonin, Potassium, Sodium Vitamin B1,

Vitamin B6, Vitamin C, and Zinc ( Naturalnews.com).

Ampicillin

Ampicillin may hinder in the production of B vitamins and vitamin K (Mindell and

Hopkins, 1998) (Naturalsnews.com).

Ranitidine

The nutrients known to be affected by the drug are Folic Acid, Iron, and Vitamin B12. It

is beneficial and recommended to supplement B-complex vitamins (Naturalnews.com).

Co-amoxiclav

Intake of augmentin may hinder the production of B-vitamins and vitamin K in the

intestine. It is recommended to undergo supplementation if prolonged used of the drug

(Naturalnews.com).

Lanoxin

Lanoxin may deplete thiamine with long term use and the use of natural licorice product

may cause low levels of potassium. It is recommended to undergo supplementation if

prolonged used of the drug (Naturalnews.com)

Captopril

Captopril may increase serum potassium with potassium-sparing diuretics. Zinc levels are

possibly depleted (Naturalnews.com).

There is no specified nutrient-drug interaction regarding Metronidazole, Nalbuphine,

Paracetamol. However, research says that Salbutamol may induce Hypokalemia.

d. Laboratory Test Results/Biochemical Findings

The routine laboratory tests that the attending physician has requested are the Complete

Blood Count, Blood Glucose, Urinalysis, Sodium and Potassium. Other tests requested are

Roentgenological Analysis and Ultrasound. These routine tests could be used to assess

specific nutrient deficiencies, or they can be useful for screening and monitoring. The data

obtained from these tests which are constantly in patient’s medical records can be used to

confirm and strengthen nutrition assessments.

On the Complete Blood Count results, an increase in lymphocyte of 0.61 mg/dL and

when TLC was computed with a value of 1830 cells/uL, is remarkable and indicative of the

patient’s malnutrition. On the other hand, the sudden decrease by 76 mg/dL and 24.3 mg/dL

in Mean Cell Volume (MCV) and Mean Cell Hemoglobin (MCH) respectively are evident

that the patient has a Chronic Disease (See Table2). Moreover on the results of Blood

Glucose, it is notable that there is an increase by 119 mg/dL which could be accounted to the

infusion of artificial glucose (IV dextrose) (See Table3). Furthermore on the results of the

Urinalysis, there is a significant increase in protein by 50 mg/dL because of artificial amino

acid infusion (hyperoncotic suspension) administered to the patient and bilirubins with the

value of 2.0 mg/dL that would apparently verify that the patient has experiencing prolonged

fasting while the acidity of the urine by the pH of 6 would confirm that the patient was

experiencing starvation (See Table4).

 Table2. Complete Blood Count with Deviated Results (January 21, 2010)

Rationale for
Laboratory Test Normal Values Actual Results Variance
Variance

Lymphocyte 0.2-0.4 0.61

Increase Malnutrition
[Computed TLC] [600-1200] [1830]

MCV 86-100 76 Decrease Chronic Disease

MCH 26-31 24.3 Decrease Chronic Disease

Table3. CBG Result (January 21, 2010)

Laboratory Rationale for

Normal Values Actual Results Variance
Test Variance

CBG 44-115 119 Increase Due to artificial

glucose Infusion

Table4. Urinalysis with Deviated Results (January 21, 2010)

Actual Rationale for

Laboratory Test Normal Values Variance
Results Variance

Protein <10 mg/dL trace 50 mg/dL + Increase Due to artificial

albumin Infusion
(hyperoncotic albumin
suspensions)

Bilirubin <0.5 mg/dL + 2.0 mg/dL ++ Increase Prolonged Fasting

pH 6 5.5 Acidic Starvation

For the Roentgenological Test, the plain abdomen/cross-table lateral part of the patient’s

body was observed. There is a bulging of the flambs with bowel distention. The bowels

appeared centrally placed with differential air fluid levels. Ascites has not ruled out according

to the roengenological test interpretation.

 The patient’s kidneys and urinary bladder are also observed through

Ultrasonography analysis. Kidneys are normal as well as the urinary bladder.

e. Clinical Assessment

The patient experienced different kind of signs and symptoms. Prior to

admission, the patient had experienced difficulty of breathing. In his medical record,

sunken eyeballs and fontanels were noted. Also, there was a deformity on the patient’s

scrotum.

As a manifestation of malnutrition, the patient has an old man’s face and muscle

wasting. Also, his abdomen was swollen due to dilated intestine (Fishbein, 1977). Based

on the patient’s roentgenological report which examines plain abdomen or cross-table

lateral, the patient has bulged flanks with bowel gas distention. The bowels appear

centrally placed with differential air fluid levels. This information supports and explains

the condition of having a distended abdomen.

VI. Nutritional Implication

As the intestine of the patient became congested, its ability to absorb nutrients decreased.

Decreased absorption may cause vomiting, dehydration and may even result to shock and can

cause kidney failure. In the case of the patient, his kidneys are normal in size with homogenous

parenchymal echopattern.

VII. Summary and Recommendations

The patient has a condition of complete intestinal obstruction secondary to incarcerated inguinal

hernia. This means that the hernia is physically blocking the intestine completely. Being a male

infant, inguinal hernia is more likely to occur. Because the testicles that have moved down into the

scrotum cannot move back to the abdomen at birth due to closed inguinal canal. This congenital

condition was a type of hernia that became stuck in the groin that cannot be massaged back to the

abdomen. Thus, herniotomy was conducted. Aside from these, the patient has a congenital heart

disease that he inherited from the side of his father.

The patient is malnourished as evidenced by his albumin level that is below normal. Physically,

muscle wasting is evident and the patient is marasmic, which means that he is both energy and protein

deficient. Old man’s face is also evident in the patient as one of the clinical signs of malnutrition.

With these evidences, his nutritional status is related to the malabsorption of nutrients due to an

obstructed intestine. Also, two days before admission, the patient has a poor appetite and did not
drink milk. These conditions may also contribute to the manifestation of malnutrition in the patient.

The patient was breastfed for one week. After that, his mother is giving him infant formula until

the present time. Also, the patient is beginning to eat solid foods while continuing bottle-feeding. His

parents often give him Marie biscuits and he can consume 1 pack per day that has 36 pieces.

As of February 24, 2010, the current weight of the patient is 4.9 kgs which is below normal for

his age. But compared to his weight before admission that is 3.2 kgs, he had gained 1.7 kgs in the

hospital for 1 month. Physically, his condition Also, there is no more muscle wasting though the

patient is still thin.

Short-term Recommendation

Breast milk is the important source of nutrients of an infant until two years

of age. As the infant grows and becomes more active, breast milk alone is not sufficient

to meet the nutritional needs of the infant. So complementary foods are needed to fill the

gap between the nutritional needs of the child and the amounts provided by the breast

milk. In the case of the patient, he was breastfed for only one week. Then, he was given

infant formula until at present. Even though the quantities of nutrients in the infant

formulas are adjusted to make them more comparable to breast milk, there are still

qualitative differences in the fat and protein that cannot be altered. Also, there is no anti-

infective and bio-active factors remain in the infant formulas. Powdered infant formula is

not a sterile product and may be unsafe if not prepared properly. Compared to infant

formula, breast milk is still the ideal food for the infant during the first six months of life.

With this, the mother must try breastfeeding her infant again little by little. It is
recommended to refer the mother to consult with a physician or a dietitian regarding her

production of milk. Also, the mother must know the maternal benefit factors of

breastfeeding to encourage her of producing breast milk again. However, it is still

dependent on the mother’s willingness and readiness to breastfeed. If not, the patient will

still be given infant formula as long as it can satisfy the nutritional requirements of the

infant.

For 4-8 weeks, the diet prescribed is 750 kcal with an additional 300 kcal to catch-up

the growth. The required energy is distributed into: C150 P20 F30. The prescribed diet consists

of infant formula with 140g powdered milk, 790 ml of water and 150g sugar. The Marie

biscuits are included in the prescribed diet since it was already introduced to the patient

by his mother. The amount of the biscuits is based on the patient’s actual intake which he

can tolerate (3/4 exchange of Marie biscuits).

If respirations increase by >5 breaths/min and pulse by >25 beats/min for two

successive 4-hourly readings, reduce the volume per feed.

After the period of 4-8 weeks, give frequent feeds (at least 4-hourly) of unlimited

amounts of a catch-up formula. Give an additional 150-220kcal/kg/d and 4-6g /kg/d of

protein in the patient’s requirement.

For monitoring, the progress is assessed by the rate of weight gain. Weigh the patient

each morning before being fed and record the weight. Each week calculate and record

weight gain as g/kg/d.

If weight gain is:

 · poor (<5g/kg/d), the infant requires full reassessment

· moderate (5-10g/kg/d), check whether intake targets are being met, or if infection

has been overlooked

When the recommended diet prescribed will be followed, the expected weight of

the patient is 6.2 kg which is his computed ideal body weight.

Long-term Recommendation

Follow-up after recovery

A child who is 90% weight-for-length (equivalent to -1SD) can be considered to have recovered.

The child is still likely to have a low weight-for-age because of stunting. Good feeding practices

and sensory stimulation should be continued at home. Show parent or carer how to:-

· feed frequently with energy- and nutrient-dense foods

· give structured play therapy

During his 8th month of age (assuming that the patient has achieved his desirable body

weight), the diet prescribed is 790 kcal C130 P15 F25. His prescribed diet consists of infant

formula with 113g powdered milk, 1080 ml and 123g sugar. The infant formula is for 3-4

feedings per day with an amount of 300 ml per feeding. His diet prescription will increase as he

grows old. Also, other foods aside from Marie biscuits will be introduce one at a time. The order

of adding solid foods to the diet of the patient is as follows:

Order of adding solid foods

1. Cereals (such as rice and wheat)
2. Fruits
3. Vegetables
4. Eggs
5. Munggo or other dried beans
6. Meat, fish, poultry
 7. Other foods

It is recommended to give a teaspoonful or less at the beginning but the patient should

not be forced to eat more than he takes willingly. If the food is still being refused by the patient, it

must be omitted in the diet. For the texture, amount and frequency of solid foods recommended

as the infant grows old, see table 7.1.

Table 7.1. Practical Guidance on the quality, frequency and amount of food to offer
children 6-23 months of age

Age Texture Frequency Amount

6-8 months Start with thick 2-3 meals per day Start with 2-3
porridge, well tablespoonfuls
mashed foods per feed,
increasing
Continue with Depending on the gradually to ½ of
mashed family child’s appetite, a 250 ml cup
foods 1-2 snacks may
be offered
9-11 months Finely chopped 3-4 meals per day ½ of a 250 ml
or mashed foods; cup/bowl
and foods that Depending on the
baby can pick up child’s appetite,
1-2 snacks may
be offered
12-23 months Family foods, 3-4 meals per day ½ of a 250 ml
chopped or cup/bowl
mashed if Depending on the
necessary child’s appetite,
1-2 snacks may
be offered
From Infant and Young Child Feeding, World Health Organization.

Other Recommendations
 The weight of the patient should be regularly checked twice a month. By 5-6 months,

weight should be doubled. By 12 months, weight should be tripled. The patient will be

referred to a social worker regarding the patient’s financial needs during hospitalization

and regular check-up. Also, vitamin and mineral supplements for growth and

development of the infant are recommended. These supplements should be consulted

with a physician.

VIII. Glossary of Medical Terms and Abbreviations

Ascites – an accumulation of fluid in the peritoneal cavity, causing abdominal swelling.

Causes include infections, heart failures, portal hypertension, cirrhosis, and various cancers.

Bilirubin – bile pigments which are orange or yellow and the oxidized form of biliverdin

which is green. These give the brown color to the feces.

Chronic Disease – a disease of long duration involving slow changes.

Diet Therapy – the branch of dietetics that is concerned with the use of food to maintain

good nutritional status, correct deficiencies that may have occurred, afford rest to the whole

body or to certain organs that may be affected by disease, adjust the food intake to the body’s

ability to metabolize the nutrients and bring about changes in body weight whenever

necessary.

Diverticulitis – inflammation of the diverticulum, most commonly of one or more colonic

diverticula. It is caused by infection and causes lower abdominal pain with diarrhea or

constipation; it may lead to abscess formation which often requires surgical drainage.
Duodenum – the first of the three parts of the small intestine that extends from the pylorus of

the stomach to the jejunum. It receives bile from the gall bladder and pancreatic juice from

the pancreas. Its walls contains various glands (including Brunner’s glands) that secrete an

alkaline juice (sucus entericus), rich in mucus, that protects the duodenum from the effects of

the acidic chime passing from the stomach.

External Oblique Fascia – connective tissue that forming membranous layers of variable

thickness in the body.

Food – anything that when taken into the body, serves to nourish, build and repair tissue.

Hernia – the protrusion of an organ or tissue out of the body cavity in which it normally lies.

Herniotomy – excision of the hernia sac: the first stage of the surgical repair of the hernia.

Hiatal Hernia – it occurs when a part of the stomach protrudes above an opening in the

diaphragm, the muscle wall that separates the chest cavity from the abdominal cavity.

Ileum – the lowest of the three portions of the small intestine that runs from the jejunum to

the ileocecal valve.

Indirect Incarcerated Inguinal Hernia - a condition wherein the hernia becomes stuck in

the groin or scrotum that cannot be put back to the abdomen. A part of the intestines

protrudes through an opening in the lower part of the abdomen, near the groin, called the

inguinal canal.

Inguinal Hernia - occurs when a section of the small intestine protrudes through abdominal

muscles, causing a lump in the groin. In men, the hernia often protrudes into the scrotum, the

sac that holds the testes.

Intestinal Obstruction – the blockage of the small intestine or colon that prevents food and

fluid from passing through it.

Jejunum – the middle part of the small intestine. It comprises about two-fifths of the whole

small intestine and connects the duodenum to the ileum.

Nutrition – the study of food in relation to health.

Omentum – a double layer of peritoneum attached to the stomach and linking it with

abdominal organs, such as the liver, spleen and intestine.

Peritoneum – the serous membrane of the abdominal cavity.

Roentgenological Analysis – X-ray analysis

Scrotum – the paired sac that holds the testes and epididymides outside the abdominal

cavity.

Strangulated Inguinal Hernia – it is the condition when the blood supply to the incarcerated

small intestine is jeopardized.

Testicles – either of the pair of male sex organs within the scrotum.

Ultrasonography – the use ultrasound, usually in excess of 1 MHz to produce images of

structures of the human body that may be observed in the TV screen and subsequently

transferred to photographic films.

Urinalysis – the analysis of urine using physical, chemical and microscopical tests to

determine the proportions of the normal constituents and to detect alcohol, drugs, sugar, or

other abnormal constituents.

IX. References/Literature Cited

Braubwald, Eugene et. al. Harrison’s Principles of Internal Medicine. 15th ed. McGraw-Hill

Medical Publishing Division: New York.2001.

Burnakis TG & Mioduch HJ: Combined therapy with captopril and potassium supplementation: a

potential for hyperkalemia. Arch Intern Med 1984; 144:2371-2372.

California Teachers Association [CTA]. The Carewise Guide. Washington: Academia

Press. 2002.

Cataldo C., Whitney E. and Rolfes S. Understanding Normal and Clinical Nutrition.

Thompson Wadsworth: USA.2002.

Claudio, Virginia S. et. al. Basic Diet Therapy for Filipinos. Philippines: Merriam and

Webster Inc. 1983.

Claudio, Virginia S. et al. Basic Nutrition for Filipinos. Manila: Merriam and Webster

Bookstore Inc. 2004. 5th ed.

Food and Nutrition Research Institute – Department of Science and Technology

(FNRI-DOST). International Reference Standards. Philippines: FNRI. 1978.

Food, Nutrition and Research Institute. Department of Science and Technology.

 Food Composition Tables. 1997.

Food Nutrition and Research Institute.Department of Science and Technology.

Food Exchange List 2008.

Food Nutrition and Research Institute. Department of Science and Technology.

Recommended Energy and Nutrient Allowances. 2002.

Lagua, Rosalinda T. and Virginia S. Claudio. Nutrition and Diet Therapy Dictionary

(Philippine Edition). Manila: Meriam Webster Bookstore. 2004.

Longo, Dan L., et al. Harrison’s Principles of Internal Medicine. USA: McGraw Hill.

2001.15th ed.

Mahan, Kathleen L. Sylvia Escott-Stump. Krause’s Food, Nutrition and Diet Therapy.

11th ed. Singapore: Elsevier PTE LTD. 2004.

Martin, Elizabeth A. et al. The Bantam Medical Dictionary. USA: Market Publishing

House Ltd. 2000.

MIMS Annual Philippines. MediMedia: Singapore.2002.

MIMS Philippines 103rd edition. Wong Mei Chan: Singapore. 2005.

Mindell, E, Hopkins V: Prescription Alternatives. New Canaan, CT: Keats Publishing, Inc,

1998; p. 336.

Tanchoco, Celeste C. 1994. Diet Manual. 4th ed. Philippines: FNRI.

Tanchoco, Celeste C. 1994. Food Exchange List. 3rd Revision. Philippines: FNRI.

Tanchoco, Celeste C. 2000. Nutritional Guidelines for Filipinos. Philippines: FNRI.

Tanchoco, Celeste C. 2002. Recommended Energy and Nutrient Intakes.

Philippines: FNRI.

Whitney, Eleanor. Sharon Wolfes. Understanding clinical and Dietary Nutrition. USA:

Wadsworth Publishing Company. 1999.

Augmentin side effects, nutrient depletions, herbal interactions and health notes.2007. retrieved

February 27 2010 from http//:www.naturalnews.com.

Ampicillin side effects, nutrient depletions, herbal interactions and health notes.2007. retrieved

February 27 2010 from http//:www.naturalnews.com.

Captopril side effects, nutrient depletions, herbal interactions and health notes.2007. Retrieved

February 27 2010 from http//:www.naturalnews.com.

Lanoxin side effects, nutrient depletions, herbal interactions and health notes.2007. Retrieved

February 27 2010 from http//:www.naturalnews.com.

Ranitidine side effects, nutrient depletions, herbal interactions and health notes.2007. retrieved

February 27 2010 from http//:www.naturalnews.com.

Captopril.2010. retrieved February 27 2010 from http//:www.naturalnews.com.

Intestinal Obstruction.2010.retrieved February 27 2010 from http//:www.freeMD.com

Intestinal Obstruction.2010. Retrieved February 27 2010 from http//:www.mayoclinic.com

Intestinal Obstruction.2010. retrieved February 27 2010 from http//:www.merck.com

Inguinal Hernia.2010. Retrieved February 27 2010 from http//:www.mayoclinic.com

Integrative Medical Arts Group Inc. IBISmedical.com. Copyright ©1998-2000,

Intestinal Obstruction. 2001. Encyclopedia of Medicine by Tish Davidson. Retrieved March 4 2010

from http://www.freearticles.com
 I. Appendices

A. Nutrition Care Plan

PROBLEM LIST:

Classification of
Medical Problem Nutritional Problem
Problem

Diagnosis Intestinal Obstruction secondary to Indirect Marasmus

Incarcerated Inguinal Hernia
Physiolog • Malabsorption • Malnutrition
ical
Findings
Symptom • Pain and discomfort in the groin • Loss of appetite
• Swollen scrotum around testicles
• Old man’s face
• Vomiting and diarrhea
• Muscle wasting
• Swelling of the abdomen

• Abdominal tenderness

• Increase in lymphocyte levels

Abnormal Findings • Clogged intestines (x-ray)

• Increase in CBG levels

• Increase in bilirubin levels

• Urine pH of 5.5, acidic

• Decreased albumin level

Behavior - Loss of appetite

SUBJECTIVE

• Name: Matt Joven Cajipe

• Age: 7 months old
• Birth Date: September 20, 2009
• Gender: Male
• Address: Trece Martirez, Cavite
• Occupation: N/A
• Education attainment: N/A
• Religion: Roman Catholic
• Birth Weight: 3.2 kg
• Weight upon Confinement: 3.2 kg
• Chief Complaint:
Difficulty in Breathing
Cough
• Signs of Nutritional Problem:
Loss of appetite
Old man’s face
Muscle wasting
Sunken eyeballs and fontanels
Swollen abdomen

OBJECTIVE

• Physician’s Diagnosis/Impression: Complete Intestinal Obstruction secondary to

Indirect Incarcerated Inguinal Hernia.
• Medication prescription:
 Gentamicin, Furosemide, Metronidazole, Ampicillin, Ranitidine, Paracetamol,
Co-amoxiclav, Nalbuphine, Lanoxin, Captopril
• Nutritional Support: The patient was given IVF upon admission

LABORATORY TEST RESULTS

Complete Blood Count (January 21, 2010)

Rationale for
Laboratory Test Normal Values Actual Results Variance
Variance

Hemoglobin 125-160 130 Normal -

Hematocrit 0.38-0.50 0.39 Normal -

WBC Count 5-10 5.89 Normal -

Neutrophile 0.4-0.6 0.21 Normal -

Basophile 0.0-0.1 0.00 Normal -

Lymphocyte 0.2-0.4 0.61 Increase Malnutrition

Monocyte 0.02-0.08 0.18 Increase

Reticulocyte 5-15 0.00 Decrease -

RBC count 4.56-5.5 4.56 Normal -

Platelet Count 150-350 220 Normal -

MCV 86-100 76 Decrease Chronic Disease

MCH 26-31 24.3 Decrease Chronic Disease

MCHC 310-370 319 Normal -

MDV 9-13 0.00 Decrease

(January 21, 2010)

Rationale for
Laboratory Test Normal Values Actual Results Variance
Variance

CBG 44-115 119 Increase Malabsorption

 Urinalysis (January 21, 2010)

Rationale for
Laboratory Test Normal Values Actual Results Variance
Variance

Protein <10 mg/dL trace 50 mg/dL + Increase Dehydration

Bilirubin <0.5 mg/dL + 2.0 mg/dL ++ Increase Prolonged Fasting

Urobilirogen <2.0 mg/dL + 2.0 mg/dL + Normal -

Glucose <50 mg/dL trace Negative -

pH 6 5.5 Acidic Starvation

Blood Negative Negative Normal -

Ketone Negative Negative Normal -

Nitrite Negative Negative Normal -

Leukocytes Negative Negative Normal -

Clarity Turbid Turbid Normal -

Specific Gravity 1.010-1.025 mg/ml 1.024 Normal -

Color Dark Amber Dark Amber Normal -

(January 24, 2010)

Laboratory Test Normal Values Actual Results Variance Rationale for Variance

Sodium 135-145 141 Normal -

Potassium 3.5-5.1 3.61 Normal -

ASSESSMENT

Anthropometric The nutritional status of the infant upon

admission was below normal using the
nutrition index of IRS (weight-for-age)

Biochemical

Clinical The patient has distended abdomen because of

the bulged flanks with bowel gas distention
seen in the roentgenological report.

Old man’s face and muscle wasting are evident

due to severe malnutrition.

Sunken eyeballs and fontanels

There is a deformity in the patient’s scrotum

Dietary

PROGNOSIS

Short-term Objective Intervention

For 4-8 weeks, the patient is expected to:

Have an improvement in his disease Removal of hernia (herniotomy)
condition and enhance his appetite
Be breastfed by the mother little by little if The mother of the patient will undergo
the mother can produce breast milk already. nutrition counseling focusing on the
If not the patient will continue taking advantages of the breastfeeding.
formula milk
The prescribed diet for the infant:

Diet Rx Energy 1050 kcal C150 P20 F30

This includes formula milk and Marie Biscuits

 according to the actual intake of the infant.
Achieve Catch up growth Progress is assessed by the rate of weight gain.
• Weigh child each morning before being fed.
Plot weight.
• Each week calculate and record weight gain
as g/kg/d.

Long term Objective Intervention

For 4-6 months, the patient should be able

to:
Attain and maintain his desirable body
weight
Take his medications regularly until his
condition improves
Take vitamin and mineral supplements for
growth and development
Normalize biochemical values such as
protein, total lymphocyte count, bilirubin,
etc
Follow his prescribed diet of solid foods
while still continuing taking formula
milk/breast milk (if the mother would still
be able to produce milk):
Diet Rx 790 kcal C130 P15 F25
Referral to a social worker regarding
patient’s financial needs
Refer to a doctor regarding the prescription
of supplements
Regular check-up and referral to a social
worker regarding hospital expenses

Meal plan:

Diet Rx Energy 1050 kcal C150 P20 F30

Food items Exchange/amount Energy (kcal)
Marie crackers ¾ exchange 75
Formula Milk

powdered milk 140 g 375

Water 930 ml
Sugar 150 g 600
Number of feedings: 4-5 times a day
Amount per feeding: 210 ml
TOTAL 1050

Long-term Recommendation (4-6 months)

Diet Rx Energy 790 kcal C130 P15 F25

Other Recommendations

Maintain healthy weight by eating a variety of foods and a balance diet. Do not smoke

later in life which may cause a chronic cough and can lead recurrence of inguinal hernia. Avoid

lifting heavy objects to prevent pressure on the abdominal muscles.

B. Computations

Short-term Recommendation

Food Item C (g) P (g) F (g) E (kcal)

Marie 17.25 1.5 - 75

1. Determine the ideal body weight of the infant

For less than 6 mos :

IBW = BW (g) + (age in months ×600)

= 3200 + (5 ×600)

= 3200 + 3000

= 6200 ~ 6.2 kg

2. Determine the nutrient requirements

Calories= 110-120 kcal per kg IBW

Calories = 120 kcal × 6.2 kg

= 744 Kcal ~ 750 kcal

Protein= < 6 mos 1.5-2.5 g per kg IBW

CHON = 2.5g × 6.2

= 15.5 ~ 15g CHON

Fluids 150 ml per kg IBW

Fluids = 150 ml × 6.2

= 930 ml

3. Determine the amount of milk needed

Milk Kcal Protein

Powdered whole milk 40 kcal/tbsp 2 g/Tbsp

a. The amount of milk to meet the protein requirement

Protein= 20 g -1.5g (the required amount of protein which is 15 g was

subtracted by the amount of protein from the ¾
exchange of Marie biscuits which is 1.5 g).

= 18.5 g (the required amount of protein of the infant for the milk
formula)

2 g = 18.5 g (1 Tbsp= 15 ml)

15 ml x

x = 138.75~ 140 g of powdered milk

40 kcal/tbsp= x/ 9.33tbsp (1Tbsp/15ml= x/101ml)

= 373.33 kcal~ 375 kcal (the caloric value of the amount of milk )

b. The amount of CHO to be added in the form of sugar

Total caloric requirement: 750 kcal

Total calories from the milk: 375 kcal

Total calories from the Marie Biscuits: 75 kcal

Sugar = 1050 kcal – 450 kcal (the caloric values from the powdered milk and
marie biscuits were subtracted)

= 600 kcal/4kcal/g
 = 150 g of sugar

c. Amount of water to dilute the formula

930 ml – 140 ml= 790 ml of water

Final formula

Powdered milk 140 g

Water 790 ml

Sugar 150 g

Size or amount of feeding

age in months + 2

5 + 2 = 7 oz per feeding (210 ml)

Number of feedings per day

= 930 ml/ 210ml

= 4.4 ~ 4-5 feedings/day

Long-term Recommendation

IBW = BW (g) + (age in months ×600)

= 3200 + (8 ×500)

= 3200 + 4000
 = 7200 ~ 7.2 kg

Calories = 110 cal ×7.2

= 792 ~ 790 kcal

CHON = 2g × 7.2

= 14.4 ~ 15g

Fluids = 150 ml × 7.2

= 1080 ml

Amount of Milk

2g/15ml = 15g/x

x = 112.5 ~ 112 g (300 kcal)

Sugar = 790 kcal – 300 kcal

= 490 kcal/4kcal/g

=122.5 ~123 g

Size or amount of feeding

 8 + 2 = 10 oz (300 ml)

Number of feedings per day = 1080 ml/ 300ml

= 3.6 ~ 3-4 feedings/day

MONITORING AND EVALUATION

• Regular checking of body weight twice a month. By 5-6 months, weight should

be doubled. By 12 months, weight should be tripled.

• Undergo regular biochemical tests every month to check whether values of

bilirubin, protein, etc have normalized.

• Regular consultation with a physician every month.

• Regular consultation with a dietitian regarding his nutritional needs and for the

revision of nutritional care plan if the objectives are not met.

C. Questionnaire

Personal Data

Name
Age
Sex
Civil Status
Date of Birth
Place of Birth
Place of Residence
Type of Residence
Occupation
Income Bracket
Socioeconomic Status
Religion and Belief
Religion Taboos
Hobbies/Recreation
Mother
Occupation
Medical History
Nutritional Status
Father
Occupation
Medical History
Nutritional Status
Name and Age of
Siblings

Personal Vices

Nutritional and Dietary Information

Food Preferences

Food Likes
Food Dislikes
Preferred Cooking Method
Food Allergies
Supplements
Changes in Body Weight

For Pediatric Cases: Breastfeeding and Weaning Information

Was the child breastfed?

If yes, for how long?

If not, why?

If not, what is the milk formula used?

What is frequency of feeding of milk formula?

Exclusive or Complementary Feeding?

If Exclusive, what is the feeding frequency?

If Complementary, what milk formula?

If Complementary, what is the feeding frequency of milk formula?

Problems encountered:

24-hour Food Recall

Time and Place Menu Description HH Measure

Breakfast

AM Snacks

Lunch

PM Snack

Supper

MN Snack
Diet History

Fluid
Usual fluid intake
Recent change in amount
Beverage preferences
Frequency on intake
Physiological
A. Teeth/Mouth
Teeth Condition
Dentures
Chewing Difficulties
Soreness in mouth
Swallowing Difficulties
Choking
Recent Changes in Taste
B. Gastrointestinal Problems
Excessive Belching
Indigestion
Nausea/Vomiting
Bowels
1. Constipation or Diarrhea
2. Changes in movements
3. Frequency
4. Use of laxatives/enemas
Urination
Difficulties in urination

Anthropometric Data

Height
Weight
Circumferences:
1. MUAC
2. MAAC
3. Waist
4. Head
Ratio:
1. Head/Chest
 2. Waist/Hip
Body Mass Index
BMI Classification

Biochemical Test Results

Serum albumin
Serum transferrin
Serum cholesterol
Serum triglycerides
RBS/FBS
Hemoglobin
WBC
Lymphocytes
Total Lymphocyte Count
Blood Urea Nitrogen
Creatinine
Bilirubin

Clinical/Medical Information

Chief Complaint

Diagnosis

History of Present Illness

Drugs Prescribed

Medication Generic Name Brand Name Indication Administration

Medical Procedures
D. Copy of Letter (Received Copy)