1. Study Case 4
GROUP MEMBERS :
Nur Faten bt Abu Samah 0919308
Nurul Alia Aqilah bt Samiun 0910124
Norhafatini bt Aziz 0917272
Nur Syafiqa bt Mohd Zulkefli 0915972
Nur Athirah bt Amran 0918654

2. A 16 years old, Indian boy alleged with MVA. He
was admitted to hospital with acute subdural
hematoma. Decompressive craniectomy has
been done and patient was referred to dietitian
for enteral Ryle’s tube feeding regime.

3. MVA (Motor vehicle
accident )
 Major cause of internal and external injury
 Motor vehicle accident injuries are as a
direct result of the force of the impact
and the biomechanics of injury.
 Most motor vehicle accidents are the
typical hyperextension flexion injuries, or
more commonly known as "whiplash"
injuries.

4. Acute subdural
hematomas
 the result of a serious head injury
 tiny veins between the surface of the
brain and its outer covering (the dura)
stretch and tear, allowing blood to
collect.
 The bleeding fills the brain area very
rapidly, compressing brain tissue.
 This often results in brain injury and may
lead to death.

5. Decompressive
Craniectomy
 the removal of a large area of skull to
increase the potential volume of the
cranial cavity
 aiming at reduction of raised intracranial
pressure.
 At the beginning of the last century,
Kocher asserted that "if there is no CSF
pressure, but brain pressure exists, then
pressure relief must be achieved by
opening the skull."

6. Ryle’s tube feeding
o nasogastric enteral feeding (adult
feeding or stomach tube)

7. ANTHROPOMETRY DATA
 Height: 1.63m
 Weight : 51kg
 BMI-for-age percentiles (Boys, 2 to 20
years)
= 25th percentiles ( normal)

8. OBJECTIVE
 To provide suitable enteral feeding
product
 To preserve lean body mass
 To increase protein synthesis
 To improve immune and muscle function
 To promote rapid recovery
 To shorten hospital stay
 To reduce the risk of morbidity

9. PRINCIPLES
 By providing suitable enteral product to
achieve adequate calories and energy
intake
 By giving high protein intake up to 1.5g/kg
body weight to promote wound healing
 By educate patient and caregiver about
hygiene and sanitation of enteral feeding

10. IMPLEMENTATION
 Elevate the head of the bed 30 to 45
degree during feeding and 30 to 60
minutes after bolus feeding.
 Tube feeding should be routinely flush with
20 to 30 ml of water to prevent of
occlution.

11. Value Indication Normal
BIOCHEMICAL DATA value
Sodium 137 mmol/L Normal 135-150
mmol/L
Potassium 3.9 mmol/ L Normal 3.5-5.1
mmol / L
Urea 5.0 mmol/L Normal 2.9-7.9
mmol/L
Creatinine 44 µmol/L Normal 35-132
µmol/L
Albumin 39 g/L Normal 35-50 g/L
Total protein 70 g/L Normal 60-80 g/L

12. NUTRITIONAL DIAGNOSIS (PES)
High protein requirement as related
to acute subdural hematoma as
evidence by post operative surgery

13.
OBJECTIVE & PRINCIPLE
Objective Principle
1. To provide Consume high biological value
protein food per day such as
animal derived food : meat,
chicken, fish
2. To minimize weight loss • Consume adequate calorie
and nutritionally balance food
per day
• Avoid skipping meal
3. To prevent infection Consume adequate intake of
micronutrients to increase
immune system
4. To inculcate hygiene practise To educate patient and
caregiver on hygiene of the tube
by flushing with 30 ml of water
before and after feeding.

14. NUTRITION INTERVENTION
 Calculation of Energy Requirements
 BMI= 19.19 Weight = 51kg Height = 163cm
Age= 16 years old
 Harris – Benedict calculations
TEE = 66.5 + 13.8(W) + 5(H) – 6.8(A)
= 66.5 + 13.8(51) + 5(163) – 6.8(16)
= 1476.5 kcal/day
BEE = 1476.5 × AF × IF
= 1476.5 × 1.2 × 1.3
= 2303.34 kcal/day
* AF= 1.2 (in bed) IF=1.3 (major surgery)

15. WHO Formula
BEE = 17.5 (W) + 651
= 17.5 (51) + 651
= 1543.5 kcal/day
Average calorie intake = 2303.34 + 1543.5
2
= 1923.42 kcal/day
~ 2000 kcal/day

16. CHO = 55 x 2000 = 1100
100 4
= 275 g
PRO = 1.5 g/kg x 5.1 kg
= 76.5 g x 4 x 100
2000
= 15.3 %
Fat = 100% - 15.3% - 50%
= 29.7 x 2000 = 594
100 9
= 66 g

17. Step 1
Perative (RTU)
50 ml 3 hr / 8x /d
kcal = 50 ml x 8
= 400 x 1.3
= 520 kcal
CHO = 0.1772 g x 50 ml
= 8.86 x 8
= 70.88 g

18. PRO = 0.0666 g x 50 ml
= 3.33 g x 8
= 26.64 g
Fat = 0.0374 g x 50 ml
= 1.87 g x 8
= 14.96 g
If pt can tolerate 1-2 feeding, go to step 2

19. Step 2
Perative (RTU)
100 ml 3 hr / 8x /d
kcal = 100 ml x 8
= 800 ml x 1.3 kcal
= 1040 kcal
CHO = 0.1772 g x 100 ml
= 17.72 g x 8
= 141.76 g

20. PRO = 0.0666 g x1500 ml
= 6.66 g x 8
= 53.28 g
Fat = 0.0374 g x 100 ml
= 3.74 g x 8
= 29.92 g
If pt can tolerate 1-2 feeding, go to step 3

21. Step 3
Perative (RTU)
150 ml 3 hr / 8x /d
kcal = 150 ml x 8
= 1200 ml x 1.3 kcal
= 1560 kcal
CHO = 0.1772 g x 150 ml
= 26.58 g x 8
= 212.64 g

22. PRO = 0.0666 g x150 ml
= 9.99 g x 8
= 79.92 g
Fat = 0.0374 g x 150 ml
= 5.61 g x 8
= 44.88 g

23. Add Modular formula = MCT oil to increase
calorie intake per day without increase
protein intake.
10 ml 6 x/d
Kcal = 10 ml x 7.7 kcal
= 77kcal x 6
= 462 kcal
Fat = 0.98 g/ml x 10 ml
= 9.8 g x 6
= 58.8 g

24. Thus , 150 ml Perative (8 times/day) + 10 ml MCT oil (6
times/day) resulting :
Total calorie = 1560 kcal + 462 kcal
= 2022 kcal
Total CHO = 212.64 g
Total PRO = 79.92 g
Total Fat = 44.8 g + 58.8 g
= 103.68 g
* Before and after feeding, flush with 30 ml water