P17110174088 - Arfiani Puspa Kania - D3 Gizi 2B
P17110174088 - Arfiani Puspa Kania - D3 Gizi 2B
P17110174088 - Arfiani Puspa Kania - D3 Gizi 2B
NIM : P17110174088
Soal : Ulcerative Colitis
Program Studi : D-3/Sarjana Terapan Gizi *
Patient History: LG is a 32 yo M with h/o UC and has begun traditional medical treatment. Pt
reports being in the middle of a flare when diagnosed by PCP. He struggles to handle its severity
(bloody diarrhea every hr for 4 weeks) and the debilitation he feels (inability to sleep, work, eat,
have a normal lifestyle). His PCP Dr. Stoma has referred him to see the Dietitian to help educate
patient on new diagnosis and relieve his symptoms. At this point in time, LG has refused surgery.
PMH: anxiety, depression
Meds: Prednisone, Wellbutrin, antibiotics
Family hx: mother died of colon CA at 55y
Physical History:
General Exam: thin male in mild distress
Vitals: Temp 100.1 F, BP 102/68mm Hg, HR 90 BPM, RR 18
Ht: 70” Wt: 105lb UBW 135lb (last year)
Labs:
Na: 133 Cl: 103 BUN: 28 Glu: 200
K: 3.6 CO2: 26 Cr: 0.6 ALB 2.5
Hemoglobin 10 Hematocrit 30
Total Cholesterol 190
Nutrition History: Patient tries to eat at least 1x day but occasionally will miss all 3. He has
been trying to eat more fiber as a friend told him this might stop the diarrhea. A usual day might
consist of:
Usual Dietary Intake:
Breakfast: oatmeal, raisins, tea c sugar & milk
Lunch: lentil soup, some saltines
Dinner: grilled cheese on whole grain bread with salad or cooked vegetables
Beverages: 2 x 16 fl oz water
Food allergy/intolerance: ‘almost everything causes pain’
Nama : LG
No. Register : XXXXX
Ruang/Bed :
Usia : 32
Diagnosis Penyakit : ulcerative colitis
ASSESSMENT/REASSESSMENT KESIMPULAN
ANTROPOMETRI TB = 178 cm AD-1.1.4 BB↓
BB sekarang = 47,7 kg AD-1.1.5 (Kurus Tingkat Berat)
BB dahulu = 61,4 kg
BBI = 70,2 kg
IMT = 15 (Kurus Tingkat
berat)
Diare (+)
Darah pada feses (+)
Lesu (+)
Depresi (+)
RIWAYAT GIZI DAHULU
Sarapan: oatmeal, kismis, FH -1.1.1.1 Asupan energi tidak
teh, dengan gula dan susu mencukupi
Snack: tidak ada
Makan siang: sup lentil, FH -1.2.2 Asupan makanan atau
sedikit garam kelompok makanan dan zat gizi
Snack: tidak ada tidak mencukupi
Makan malam: keju
panggang di atas roti FH -1.3 Terapi enteral/parenteral
gandum dengan salad
atau sayuran matang
Snack: tidak ada
Minuman: 2 x 16 fl oz air
PERUBAHAN DIET
A. RENCANA INTERVENSI
b. Prinsip Diet
Memberikan Diet Rendah Sisa dengan bentuk makanan saring
c. Syarat Diet
(penjelasan mengapa Energi dan Zat Gizi diberikan sesuai dengan tujuan
dan prinsip diet, pemesanan diet sesuai dengan standar diet yang meliputi:
jenis diet, bentuk makanan, frekuesi dan cara pemberian)
Protein = 202,8 g
Lemak = 338 g
Karbohidrat = 811,2 g
2. INTERVENSI EDUKASI/KONSELING
f. Sasaran : Pasien
g. Materi :
- Isi piringku
- Frekuensi makan
- Gizi Seimbang
PERENCANAAN MENU
Waktu Menu Bahan Berat (gr)
Makanan
Pagi Bubur saring Beras putih 30
giling
Telur ½ masak Telur ayam ras 50
kecap 5
Sari tomat Tomat segar 100