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

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) 1~1.251.25~1.41.4~1.71.7~2 Arginine (g/d) 不須特別補 充 1~46~8  -carotene (μg/d) 如有不足要 補充 1000~20002000~30003000~500 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; 16:6 291-294

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;6 291-294

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: 18.23 (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/ 0.8 3.9 May. 19NPO May. 30NPO9.8/ 31.7 7930/ 23.1 0.54 Jun. 1 調整配方 1200 Cal 三大三小 9.4/ 28.9 12150/ 25.3 0.42 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. 16471459 May. 17322303211280 May. 18254277201234 May. 19222320230285 May. 20244204194318 May. 21177214207133 May. 22219227159234 May. 23268261179263 May. 24205266191294 May. 25236258237201 一般管灌 1400 Cal, low salt < 5g 自備管灌 1600 Cal (PT 66g)

15. May. 31181274111233 Jun. 1309366292414 Jun. 2337408252295 Jun. 3127199109233 Jun. 413021298182 Jun. 510810986133 RI 26 U tid/ NPH 24 U hs 7a11a4p9p May. 26155230194394 May. 27178265204188 May. 28195219237220 May. 29201344240154 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/ 26.3 6850/ 18.4 12601.44142/ 5 Jun. 7NPO130/ 3.8 Jun. 9NPO10.3/ 31.4 5330/ 15.6 8313.15/0.6134/ 5.7 Jun. 10NPO9.8/ 30.4 8540/ 6.9 5897/0.8138/ 4.6 Jun. 13NPO10.2/ 31.5 3880/ 26.4 10242.815/0.82.37150/ 2.2 Jun. 15NPO10.7/ 33.6 5730/ 27.8 15939/0.6145/ 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/ 30.8 7080/ 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/ 35.2 4410/ 21.5 94841/ 1 2.9138/ 3.4 Jul. 8 一般管灌 1200 Cal 一天四餐 8.4/ 26.1 4690/ 15.3 1008 Jul. 13 特殊配方 1200 Cal 一天四餐 9.3/ 27.9 5910/ 18 10642.713/ 0.7 136/ 3.2

19. 7a11a4p9p Jun. 21220128234214 Jun. 22260169378319 Jun. 23251237377481 Jun. 24284273366405 RI 8 U tid/ NPH 8 U hs 一般管灌 800 Cal (PT 28g) 3a11a4p9p Jun. 16299338460 Jun. 17154388341 Jun. 1813074262273 Jun. 19854472243 Jun. 2020030469372 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. 2927213686256 Jun. 30328222283299 Jul. 1279428215- Jul. 239648336469 RI 20 U tid/ NPH 20 U hs 7a11a4p9p Jun. 25265198164154 Jun. 2621114787283 Jun. 27282153193172 Jun. 28208159118180 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. 3479429398364 Jul. 4463344-126 Jul. 524213553323 Jul. 629219585221 Jul. 7274237151176 Jul. 824324598139 Jul. 938115792333 Jul. 1035921283214 Jul. 113782129368 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. 12261784568 Jul. 13308146112102 Jul. 14253824898 Jul. 15263155146180 Jul. 161998113/245116 Jul. 171507055/172142 Jul. 18227174128164 Jul. 19189MBD 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. 3 1301300143011000 Jul. 4 500104015305502/150700 Jul. 5 5001500200012000 Jul. 6 11001500260010501 Jul. 7 1100105021509501/3001250 Jul. 8 6601280194011001/4001500 Jul. 9 3801125150514001 Jul. 10 2601280154012504