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    P17110174088 - Arfiani Puspa Kania - D3 Gizi 2B

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    Arfiani Kania
    This patient is a 32-year-old male diagnosed with ulcerative colitis who presents with bloody diarrhea every hour for 4 weeks and inability to sleep, work or eat normally. His labs show anemia and elevated BUN. The dietitian's assessment is that the patient has a nutrition knowledge deficit regarding his new UC diagnosis. The intervention plan includes a low-residue diet in pureed form to meet nutrient needs while minimizing stool volume. Counseling will educate on the relationship between diet and fiber for UC management. Monitoring will assess nutrition status and dietary adherence.

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    P17110174088 - Arfiani Puspa Kania - D3 Gizi 2B

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    Arfiani Kania
    59 views8 pages
    This patient is a 32-year-old male diagnosed with ulcerative colitis who presents with bloody diarrhea every hour for 4 weeks and inability to sleep, work or eat normally. His labs show anemia and elevated BUN. The dietitian's assessment is that the patient has a nutrition knowledge deficit regarding his new UC diagnosis. The intervention plan includes a low-residue diet in pureed form to meet nutrient needs while minimizing stool volume. Counseling will educate on the relationship between diet and fiber for UC management. Monitoring will assess nutrition status and dietary adherence.

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    This patient is a 32-year-old male diagnosed with ulcerative colitis who presents with bloody diarrhea every hour for 4 weeks and inability to sleep, work or eat normally. His labs show anemia and elevated BUN. The dietitian's assessment is that the patient has a nutrition knowledge deficit regarding his new UC diagnosis. The intervention plan includes a low-residue diet in pureed form to meet nutrient needs while minimizing stool volume. Counseling will educate on the relationship between diet and fiber for UC management. Monitoring will assess nutrition status and dietary adherence.

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    59 views8 pages

    P17110174088 - Arfiani Puspa Kania - D3 Gizi 2B

    Uploaded by

    Arfiani Kania
    This patient is a 32-year-old male diagnosed with ulcerative colitis who presents with bloody diarrhea every hour for 4 weeks and inability to sleep, work or eat normally. His labs show anemia and elevated BUN. The dietitian's assessment is that the patient has a nutrition knowledge deficit regarding his new UC diagnosis. The intervention plan includes a low-residue diet in pureed form to meet nutrient needs while minimizing stool volume. Counseling will educate on the relationship between diet and fiber for UC management. Monitoring will assess nutrition status and dietary adherence.

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    of 8

    Nama mahasiswa : ARFIANI PUSPA KANIA

    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)

    BIOKIMIA Na: 133 (136 – 145) BD-1.2.5 Na↑


    Cl: 103 (98 -106) BD-1.2.3 BUN↑
    BUN: 28mg/dL (8-20 BD-1.5.1 Gula darah↑
    mg/dL) BD-1.1.3 pCO2↑
    Gula darah : 200mg/dL BD-1.11.1 Albumin↓
    (70-130 mg/dL) BD-1.10.1 Hb↓
    K: 3.6 (3,5 – 5)
    CO2: 26% (22 .99 %)
    Kreatinin:0.6mg/dL (0,6-
    1,2mg/dL)
    Albumin : 2.5 g/dL (3.4 –
    4.8 g/dL)
    Hemoglobin 10 (13,4 –
    17,7)
    Hematocrit 30 (40 – 47)
    Kolesterol total 190 (<200
    mg/dL )
    FISIK-KLINIS Suhu 68,1°C (36°C- PD-1.1.1 Kurus
    37,5°C) PD-1.1.5 Lesu
    BP 102/68mm Hg PD-1.1.5 Diare
    HR 90x/mnt (60-100x/mnt) PD-1.1.9 Suhu↑
    RR 18x/mnt (12-24x/mnt)
    Total Cholesterol 190

    Tampak depresi dan


    cemas

    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

    Makanan yang dikonsumsi


    Px kurang beragam
    Kategori aktifitas Px
    sedang
    Px tidak konsumsi apapun
    sebagai selingan
    Px kurang konsumsi
    daging dan telur
    Px kurang konsumsi buah
    dan sayur
    Px belum konsumsi air
    putih 2L/hari

    RIWAYAT PERSONAL Alergi : Tidak ada CH-2.1.12 Anxiety disorder


    DAHULU
    Tidak memiliki riwayat
    penyakit keluarga CH-2.1.12 Depresi
    Aktifitas sedang
    SEKARANG
    Tidak ada aktifitas
    Depresi

    DIAGNOSA GIZI Defisit pengetahuan tentang makanan dan gizi


    (NB-1.1) berkaitan dengan diagnosis UC baru-
    baru ini yan ditandai dengan diet tinggi serat
    yang dikontraindikasikan untuk diare.
    INTERVENSI GIZI RENCANA MONITORING & EVALUASI

    ND.1.2 Modifikasi jenis atau jumlah


    makanan FH-1.1.1 (Asupan Energi Total 2000-2700kkal)
    ND.1.3 Kelompok makanan/zat gizi FH-1.2.1 (Variasi makanan, Jumlah cairan
    khusus 2L/hari)
    ND.3.2.1 Suplemen FH-3.1 (Suplemen MVM setiap hari)
    multivitamin/mineral AD-1.1 (Status Gizi Normal)
    E.1.7 Hubungan diare dan serat CH-1.1 (Edukasi)
    C.2.11 Kontrol depresi
    R.C 1.4 Kolaborasi dengan tim medis
    lain

    PERUBAHAN DIET
    A. RENCANA INTERVENSI

    1. INTERVENSI DIET (ND)


    a. Tujuan Intervensi:
     Memberikan makanan dengan sisa rendah sehingga volume feses rendah
     Tidak memperberat dan merangsang saluran cerna

    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)

     Diet rendah sisa dengan bentuk makanan saring diberikan untuk


    memenuhi kebutuhan zat gizi pasien tanpa memperberat kerja
    kolon dan volume feses kecil
     Energi cukup 1352 kkal sesuai kebutuhan pasien
     Protein cukup 202,8 g
     Lemak cukup 338 g
     Menghindari makanan berserat tinggi (maksimal 8g/hari)
     Menghindari susu dan produk olahannya
     Menghindari daging berserat kasar
     Menghindari makanan berlemak
     Makanan diberikan porsi kecil tapi sering
     Makanan diberikan secara oral

    d. Perhitungan Kebutuhan Energi dan Zat Gizi


    REE = (10 x 47.628kg) + (6.25 x 177.8cm) - (5 x 48yr) + 5 = 1352 kkal

    Protein = 202,8 g
    Lemak = 338 g
    Karbohidrat = 811,2 g
    2. INTERVENSI EDUKASI/KONSELING

    a. Tujuan :Diberikan konseling tentang hubungan gizi dengan serat

    b. Metode :Konseling (Tanya jawab untuk memecahkan masalah)

    c. Waktu :30 menit

    d. Tempat :Ruang konseling Poli Gizi

    e. Alat dan Bahan :Leaflet, food model

    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

    Selingan pagi Biskuit Biskuit 20


    Sirup Sirup rasa 10
    melon

    Siang Bubur saring Beras putih 30


    giling
    Semur daging Daging sapi 50
    Kecap 5
    Tim tahu Tahu putih 50
    mentah
    Sari jeruk Jeruk manis 100
    segar

    Selingan sore Roti panggang Roti tawar 40


    Margarin 5
    Sari tomat Tomat segar 100

    Malam Bubur saring Beras putih 30


    giling
    Ayam ungkep Daging ayam 50
    Sup tahu Tahu putih 50
    mentah
    Sari jeruk Jeruk manis 100
    segar

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