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Nutritional Care for Diabetes with Pressure Sore patient 萬芳醫院營養室 江詩雯 2005 Aug. 16.

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Presentation on theme: "Nutritional Care for Diabetes with Pressure Sore patient 萬芳醫院營養室 江詩雯 2005 Aug. 16."— Presentation transcript:

1 Nutritional Care for Diabetes with Pressure Sore patient 萬芳醫院營養室 江詩雯 2005 Aug. 16

2 Pressure sore pressure ulcer, decubitus ulcers, bed sores Stage I: non-blanchable erythema of intact skin, the heralding of skin ulceration Stage II: partial thickness skin loss involving epidermis, dermis or both Stage III: full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through Stage IV: full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures Agency for health care policy and research (1994)

3 lpig.doereport.com/ imagescooked/2037W.jpg bone muscle skin layer

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5 pressure relief care of the sore good nutrition High protein intake (24%~25% of energy) v.s. lower protein intake (14%~16% of energy) Agency for health care policy and research supported consumer guides, Chapter 15 J Am Diet Assoc 1990; 90:A130

6 Stage IStage IIStage IIIStage IV Cal (kcal/kg) 25~3525~3030~3530~40 PT (g/kg) 1~ ~1.41.4~1.71.7~2 Arginine (g/d) 不須特別補 充 1~46~8  -carotene (μg/d) 如有不足要 補充 1000~ ~ ~500 0 Vit. C (mg/d) 如有不足要 補充 建議綜合補充 250~750 Zinc (mg/d) 如有不足要 補充 建議綜合補充 25~50 H 2 O (cc/kg) 25~3025~3530~3530~40 亞培營養期刊 壓瘡的營養治療 2001 年 6 月號

7 Uncontrolled blood glucose impairs blood flow through the critical small vessels at the wound surface by impeding red blood cell permeability. The increased glucose makes the cell wall rigid, thereby impeding flow. In addition, the hemoglobin release of oxygen is impaired, resulting in an oxygen and nutrient deficit in the healing wound. Diabetic infection take longer to heal because of delayed macrophage introduction and diminished leukocyte migration, which causes a prolonged inflammatory in wound healing. Advances in skin and wound care 2003; 16:

8 CauseTreatment Decreased capillary blood flow from elevated glucose Careful monitoring and control of glucose; education Decreased insulin and anabolic hormones Increase exercise; provide adequate insulin; use anabolic agents Protein malnutrition and decreased muscle mass Increase protein intake to 1.5 g/kg per day Advances in skin and wound care 2003, 16;

9 Gender: female Age: 81 y/o Admission date: 2005 May 16 Meta C/o: fever on and off for 3 days Past disease history: DM, CAD, HCVD, Dementia, Parkinsonism Dx: 1. fever, cause ? Suspect wound infection of the pressure sore 2. UTI 3. Hyperglycemia 4. pressure sore

10 Admission records 1999 Oct. 6: Parkinsonism disease, DM, HTN 10+ yr 1999 Oct. 29: dehydration, UTI, Parkinsonism, CAD, HTN, DM 2001 May. 19: sepsis r/o bed sore (III) related, parkinsonism, old CVA, DM, HCVD, dementia 2005 Apr. 11: UTI, electrolyte imbalance, HTN, DM, old CVA, pressure sore

11 Ht: 155 cm Admission BW: 43.8 kg UBW: 40 kg (2001 yr) IBW: 53 ± 5.3 kg BMI: (underweight) BEE: 974 Cal/d TER: 1286~1403 Cal/d (AF: 1.2 SF:1.1~1.2) PT requirement: 65 g/d (1.5 g PT/kg BW)

12 Bed sore: R’t hip 8x6x2 (III) L’t hip 9x7x2 (III) May. 19 wound culture: MRSA ( Methicillin-resistant Staphylococcus aureus ) (May. 20 MRSA isolation) May. 22 sputum culture: MRSA May. 23 U/A: OB+, LE+/- May. 31 U/A: OB2+, Glu3+, RBC 12~15/HPF Medication: May. 16- MgO 1# qd sennoside 1# qdhs May. 17- Targocid 200 mg 1 vial qd (May. 24->2 vial) Jun. 1- Fortum 2 vial q8h (DC Targocid)

13 DietHb/ Hct WBC/ Lymp(%) BUN/ Crea CRP K May. 16 一般管灌 1400 Cal low salt < 5 g 32/ May. 19NPO May. 30NPO9.8/ / Jun. 1 調整配方 1200 Cal 三大三小 9.4/ / Jun. 2 調整配方 1200 Cal 三大三小 Jun. 3 調整配方 1400 Cal 三大三小 TLC=1832 正餐 300 Cal 點心 100 Cal 正餐 350 Cal 點心 100 Cal

14 RI 16 U tid/ NPH 16 U hs RI 20 U tid/ NPH 20 U hs RI 22 U tid/ NPH 22 U hs RI 24 U tid/ NPH 22 U hs 7a11a4p9p May May May May May May May May May May 一般管灌 1400 Cal, low salt < 5g 自備管灌 1600 Cal (PT 66g)

15 May Jun Jun Jun Jun Jun RI 26 U tid/ NPH 24 U hs 7a11a4p9p May May May May RI 28 U tid/ NPH 26 U hs 調整配方 1200 Cal (PT 53g) ( 三大三小 ) RI 32 U tid/ NPH 34 U hs 調整配方 1400 Cal (PT 59g) ( 三大三小 ) RI 32 U tid/ NPH 34 U hs 38.5 ℃ 自備管灌 1600 Cal (PT 66g)

16 Jun. 6~Jun. 15- NG free drainage with coffee ground -> NPO Medication: Jun. 6- Lactulose 10 ml qid Jun. 8- Gaster 1 amp q8h Jun. 9- Primperan 1 amp q8h Order renew: (Jun. 12) 1. DM 2. pneumonia with bil pleural effusion 3. UGI bleeding 4. r/o ileus Jun. 13 Bed sore: R’t hip 6x4x2 (III) L’t hip 5x4x2 (III)

17 DietHb/ Hct WBC/ Lymp( %) TLCAlb.BUN/ Crea CRPNa/ K Jun. 6NPO7.9/ / / 5 Jun. 7NPO130/ 3.8 Jun. 9NPO10.3/ / /0.6134/ 5.7 Jun. 10NPO9.8/ / /0.8138/ 4.6 Jun. 13NPO10.2/ / / / 2.2 Jun. 15NPO10.7/ / /0.6145/ 3.2 6/8 PRBC 1 U

18 DietHb/ Hct WBC/ Lymp(%) TLCAlb.BUN/ Crea CRPNa/ K Jun. 16 一般管灌 800 Cal Jun. 21 一般管灌 1000 Cal Jun. 25 一般管灌 1200 Cal 10.1/ / Jun. 29 一般管灌 1200 Cal 一天四餐 Jul. 4 一般管灌 1200 Cal 一天四餐 11.1/ / / / 3.4 Jul. 8 一般管灌 1200 Cal 一天四餐 8.4/ / Jul. 13 特殊配方 1200 Cal 一天四餐 9.3/ / / / 3.2

19 7a11a4p9p Jun Jun Jun Jun RI 8 U tid/ NPH 8 U hs 一般管灌 800 Cal (PT 28g) 3a11a4p9p Jun Jun Jun Jun Jun RI 6/8/8 U tid/ NPH 8 U hs 一般管灌 1000 Cal (PT 39g) RI 6/8/10 U tid/ NPH 12 U hs RI 6/10/12 U tid/ NPH 16 U hs RI 12/14/14 U tid/ NPH 20 U hs 38 ℃ 39.6 kg

20 7a11a4p9p Jun Jun Jul Jul RI 20 U tid/ NPH 20 U hs 7a11a4p9p Jun Jun Jun Jun RI 18 U tid/ NPH 22 U hs 一般管灌 1200 Cal, 一天四餐 (PT 41 g) RI 22 U tid/ NPH 30 U hs 一般管灌 1200 Cal (PT 47g) 38.8 kg

21 RI 28 U tid/ NPH 32 U hs 7a11a4p9p Jul Jul Jul Jul Jul Jul Jul Jul Jul RI 28 U tid/ NPH 36 U hs RI 24 U tid/ NPH 24 U hs RI 24/20/20 U tid/ NPH 30 U hs 38 ℃ 38.9 ℃ 一般管灌 1200 Cal, 一天四餐 (PT 41 g) 40.1 kg 36.7 kg

22 RI 24/18/18 U tid/ NPH 32 U hs 特殊配方 1200 Cal, 一天四餐 (PT 66g) 7a11a4p9p Jul Jul Jul Jul Jul / Jul / Jul Jul MBD RI 18/14/14 U tid/ NPH 32 U hs RI 16/12/12 U tid/ NPH 32 U hs RI 12/8/8 U tid/ NPH 32 U hs

23 MBD Jul. 18 Pressure sore: R’t hip 5x5x2 (III) L’t hip 5x4x1 (III) RI 12/ 8/ 8 U tid/ NPH 32 U hs Diet: 特殊配方 1200 Cal, PT 63g (1.56 g/kg) 三正餐 - 益力康 60 g + 補體素 (90) 10 g + 鹽 1 g/ 沖 310 c.c. 晚點心 - 益力康 50 g + 鹽 1 g/ 沖 200 c.c.

24 Discussions Calories Protein Pressure sore

25 Thanks for your attention!

26 IVTFTotalUrineStollTotal Jul Jul / Jul Jul Jul / Jul / Jul Jul


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