Script Compilation - Acute Pancreatitis

1. Describe the normal exocrine and endocrine functions of

the pancreas.

Exocrine glands secrete enzymes, ions, water, mucins and other

substances essential for digestions. So para ma-process ang
proteins, these chemicals contain trypsin and chymotrypsin.
Trypsin isang digestive enzyme na ang function ay binebreak nya
ang protein sa ating small intestine and it is secreted by the
pancreas in an inactive form, trypsinogen. Chymotrypsin isa rin
po syang digestive enzyme component ng pancreatic juice acting
in the duodenum, ginagamit ito sa paggawa ng medicine and
ginagamit din ito for redness and swelling na nag associated with
pockets of infection or abscesses, ulcer, surgery or critical illness.
Amylase isa po syang special protein na nag hehelp din po na
mag digest ng food and most of our amylase is made in the
pancreas and salivary glands. Lipase naman po ang function po
nito ay binebreak down nya po ang fats sa food para ma
absorbed sya sa ating intestines, lipase is produced in the
pancreas, mouth, and stomach. Ang pinagkaiba ng dalawa na ito
ay ang amylase tumutulong sa ating body para ibreak down ang
starches then ang lipase tumutulong ito para idigest ang fats.
These pancreatic juice are leading into a series of ducts when
food reaches into the stomach na nag reresult sa main pancreatic
duct, ang pancreatic duct or duct of wirsung, isa po syang duct na
ng jojoin sa pancreas papunta sa common bile duct, nag susupply
ito ng pancreatic juice from the exocrine pancreas which aids in
digestion. The pancreatic duct joins typical bile duct to form
Vater's ampulla, is a small opening that enters into the first
portion of the small intestine, known as the duodenum. Ito po
ang spot kung saan ang pancreatic and bile ducts release their
secretions into the small intestines. Sa ating liver and gallbladder,
the normal bile duct begins to deliver another juice from the huge
stomach called bile, ang bile mo isang digestive fluid na
pinoproduce ng liver and naka stored in our gallbladder. So our
pancreatic juices and bile delivered sa ating duodenum that helps
our body to process fats, proteins, and carbs.

Sa endocrine naman, endocrine portion consists of islet cells or

langerhans islets, and these are made up of several cells, isa dito
ang beta cells na gumagawa ng insulin na tumutulong sa ating
katawan para gumamit ng glucose for energy and glucagon which
acts to build glucose. These acts as working of key organs
including mind, liver, and kidneys para ma keep up ang legitimate
glucose level.

2. Determine the potential etiology of both acute and

chronic pancreatitis. What information
provided in the physical assessment supports the
diagnosis of acute pancreatitis?

Acute pancreatitis, isa po syang panandaliang pamamaga ng

pancreas. Maaari din po sya na minor na karamdaman hanggang
sa maging serious to life threatening condition. Isa po sa common
cause ng pancreatitis ay ang gallstones, Gallstones are hard,
pebble like pieces of material na binubo ng cholesterol or bilirubin
na nag dedevelop sa ating gallbladder, ang nangyayare po ay
yung enzyme sa ating pancreas pinipilit pabalik sa ating pancreas
at pinag babawalan nya po ito na makapunta sa ating small
intestine, isa din po ang cause ng acute pancreatitis ay ang pag
inom po ng alcohol, dahil kilala ang alcohol na nag dudulot ng
maraming toxic effects sa arcinal cells inaactivate nya po nang
prematurely ang digestive at lysosomal enzyme pati na rin ang
increase ng malapot na nilalabas na syang humaharang sa tiny
pancreatic channels. Ang hypertriglyceridemia po isa din po syang
cause ng acute pancreatitis, kapag ang triglycerides ay lumagpas
ng 10 millimoles per litre magiging present po sila sa
bloodstream mangyayare po ay ang pancreatic capillaries ay ma
hihinto na mag reresult sa ischemia kung saan ang ibang part ng
ating katawan ay hindi nakakahua ng enough na dugo pati na rin
ang release ng pancreatic lipase and acinar structural changes.
Sa chronic pacreatitis naman po, isa po syang pamamaga sa
ating pancreas na hindi gumagaling or nag iimprove, but instead
lumalala po sya at nag cacause ng irreversible damage sa ating
pancreas. Ang capacity po ng isang pasyente na nag didigest ng
food at nag poproduce ng pancreatic hormones is eventually
compromised by chronic pancreatitis. Pinaka common cause ng
chronic pancreatitis ay ang pag inom ng alcoholic drinks over a
long period of time, ibang cause din ng chronic pancreatitis ay
ang pag atake ng acute pancreatitis na sinisira po ang ating
pancreatic ducts, pag babara ng main pancreatic ducts at cause
po nito ay cancer. Isa rin po ay ang cystic fibrosis na ang
katawan natin ay gumagawa ng makapal at malagkit na mucus,
ang mucus ay nag cacause ng problems sa ating lungs, pancreas
at iba pang mga organs at ang hereditary disease ay
inflammation ng pancreas na nag lelead ito sa mga sintomas at
included dito ang fatty stools, weight loss at poor absorption ng
nutrients sa food. Mga taong may hereditary pancreatitis ay nag
dedevelop ng chronic pancreatitis at patuloy na pamamaga ng
pancreas. Type 1 diabetes at pancreatic cancer are mas common
sa adults na mayroong genetic pancreatitis or hereditary
pancreatitis.

Para po sa physical examination diagnosis ng acute pancreatitis

Ito po ay:
 Transabdominal ultrasound
Ito po ay common na ginagawa during hospitalization para po ma
evaluate ang gallbladder for stones kasi po ang gallstones ay
common cause ng acute pancreatitis, ang gagawin po ni ultra
sound is gumagamit po sya ng sound waves that bounce off the
pancreas, gallbladder,liver and other organs, yung echoes po nya
nag gegenerate ng impulses para mag create ng image na
tinatawag na sonogram sa video monitor, kapag ang gallstones
ay gumagawa ng inflammation, ang sound waves mag bobounce
sa kanila at makikita ang kanilang location.

 Endoscopic Ultrasound or (EUS)

Itong test na ito hindi po sya commonly required during acute
pancreatitis compare sa transabdominal ultrasound, ito po ay
medyo invasive, a physician passes a flexible na tube pababa sa
ating stomach then may camera po sya at ultrasound probe na
nakakabit sa end ng tube wich enable the physician na makita
ang imahe ng gallbladder, pancreas at liver, yung mga image po
neto ay sensitive compare sa transabdominal ultrasound na hindi
nakikita kasi masyadong maliit sa ating gallbladder and bile ducts
at na vivisualize ang abnormalities ng pancreas

 Magnetic resonance cholangiopancreatography or (MCRP)

Yung MCRP gumagamit sya ng Magnetic Resonance imaging or
MRI, ito po ay noninvasive procedure kung saan nag porpoduce
sya ng cross section image ng parts ng ating body, si patient ay
hihiga sa cylinder like tube then ang technician mag iinject ng
dye sa ugat ng pasyente na tumutulong makita ang pancreas,
gallbladder, pancreatic ducts and bile ducts, ito po ay sensitive
test para sa evaluating ng gallbladder, bile ducts at pancreas na
nag cacause ng acute pancreatitis

 Computerized tomography or CT
Ang ct scan po ay noninvasive radiograph or Xray na gumagawa
ng 3 dimensional images ng bodyparts, si patient ay hihiga sa
table na iislide sa donut shaped machine, pineperform po ito
several days into hospitalization para ma evaluate ang extent of
pancreatic damage kapag ang pasyente ay hindi po sya nag
rerecover quickly as expected

3. What laboratory values or other tests support this

diagnosis? List all abnormal values and
explain the likely cause for each abnormal value.

 (Basa muna nung nakabullet), the Dehydration is caused by

excessive alcohol intake because alcohol is diuretic leading to
increased urine output. Vomiting is another reason for
dehydration, since vomit contains fluid. Dehydration is
supported by the amber color of urine, skin turgor tenting, and
dry skin seen in nursing assessment. AKI may be caused by
 the reduced blood flow to the kidney due to decreased blood
volume instigated by dehydration. Proteinuria or the presence
of protein in urine is caused by the ineffective filtering of the
kidney due to the kidney problem/ AKI.

 (Basa muna nung nakabullet), Since the patient has acute

pancreatitis, the beta cells that produce insulin to regulate the
blood sugar levels are damaged that is why there is still
hyperglycemia. It also indicates that the patient will have an
increase energy expenditure to repair any damaged cells,
tissues, or organs because the patient is in Flow phase of
metabolic response to stress.

 (Basa muna nung nakabullet), Gluconeogenesis is a process

that transforms non-carbohydrate source of energy like
proteins and fats into glucose. The presence of ketones in
urine may signal that the main source of energy that is being
used in the body is fat. Additionally, it may also signal a
potential kidney problem since the kidneys filtering ability is
compromised because of AKI.

 (Basa muna nung nakabullet), Liver damage may be caused

by the Excessive alcohol intake by the patient as evidenced by
his alcohol use of 6 pack beer, 4-5 “shots” of bourbon daily,
 and drinking beer, bourbon, wine, & other mixed drinks. Since
alcoholic drinks are rich in fat and the patient consumes it in
large amounts, too much fat stored in the liver can cause liver
inflammation that can damage the organ and create scarring.
Bilirubin is a brownish yellow substance which is produced
when old RBC break down. The liver releases bilirubin in bile.
Since the liver is not functioning properly, the bilirubin is not
properly excreted from the body.

 (Basa muna nung nakabullet), Albumin and CRP are

considered as Acute-Phase Proteins. They are inflammation
markers produced by the liver in response to inflammation.
There are 2 types of acute phase proteins: the negative and
positive acute phase protein. The albumin is a negative acute-
phase protein. Their concentrations will decrease during the
presence of inflammation. While the C-reactive protein is a
positive acute phase protein that will increase in concentration
during inflammation. The abnormal values of these 2 acute
phase proteins tells that there is an ongoing inflammation in
the body. The inflammation is evident because of the
abdominal tenderness and rebound that the patient has and it
is possible that it is caused by acute pancreatitis.

 (Basa muna nung nakabullet), this may be caused by the

excessive intake of alcoholic beverages that are very high in
 fat and the lack of physical activity of the patient as evidenced
by Mr.JM’s history

 (Basa muna nung nakabullet), Neutrophils, Segs or

Segmented Neutrophils, and Bands are white blood cell count
indices. Neutrophils are the type of white blood cell that helps
to heal damages tissues, and resolves infections by
phagocytosis of antigens like bacteria, viruses, fungi, and
cancer cells. Segs or Segmented Neutrophils are the mature
neutrophils that responds to inflammation and infection while
the Bands are the immature form of neutrophils. Their levels
are high because there is an ongoing inflammation in the
body like the abdominal distention and the acute pancreatitis
and it is also plausible that there might be an infection.
4. The physician lists an APACHE score in his note. What
factors are used to determine this
score? What does this mean? Ranson’s Criteria and the
Atlanta Criteria are also used to
determine the severity of pancreatitis. Define each of
these sets of criteria.

Each acute physiologic variable has a given range of value with

corresponding points as seen on the table. Either the °F or °C can
be used to get the points for temperature. In the case of Mr. JM,
his temperature upon admission is 101.7 °F which is equivalent
to 1 point. The heart rate is the measure of the number of time
the heart beats per minute. Per admission history of Mr. JM, his
HR is 108 bpm which is equivalent to 0 point. The MAP or the
Mean Arterial Blood Pressure is the average pressure in a
patient’s arteries during one cardiac cycle (approximately 0.8
seconds). To calculate the MAP, we can add the Systolic blood
pressure to twice the product of Diastolic blood pressure divided
by 3. Mr.JM’s blood pressure is 132/96. Using the
aforementioned formula, his MAP is 108 which is equivalent to 0
point. The Respiratory rate is the number of breaths taken per
minute. The patient’s RR is 27 which is equivalent to 1 point.
The 5th factor which is the Oxygenation, We use the Partial
Pressure of Oxygen in the ABGs which is equivalent to 95 which
has the score of 0. The serum sodium is 138 & the potassium is
3.5 in the lab results which is both equivalent to 0 point. While
the creatinine is 1.6 in lab result which has the value of 2 points
in the APS. We use the Arterial pH as seen in the ABGs and it’s
value is 7.40 which equals to 0 point. The WBC and hematocrit
are 1 point each. Finally, the Glasgow Coma Scale of Mr. JM is 14
since it is stated in the Physical exam on page 5 that he is alert
and oriented to person, place, and time. The average point of
the Acute Physiologic Score is 1.6 or we can use 2.
Mr. JM is only 29 years old , that is why his Age point is 0 and he
has a history of Appendectomy that is why his Chronic Health
Score is 2. Adding the Acute Physiologic Score of 2 to the
equation, the APACHE II score of Mr. JM is 4.
As a general rule, the higher the APACHE score, the higher the
mortality rate and the more severe the disease is.

SCRIPT FOR RANSON’S CRITERIA

Ranson’s criteria is one of the earliest scoring systems to assess
the severity of acute pancreatitis and continue to be widely used.
Ranson’s criteria is used to predict the severity and mortality of
acute pancreatitis. Five parameters are assessed on admission,
and the other six are assessed at 48 hours post-admission.
One point is given for each positive parameter for a maximum
score of 11.
At admission, the measured parameters include age over 55
years, elevated white blood cell count (WBC), hyperglycemia (i.e.,
elevated blood glucose), elevated lactate dehydrogenase (LDH),
and elevated serum aspartate transaminase (AST). At 48 hours,
the criteria include low hematocrit, elevated blood urea nitrogen
(BUN), low serum calcium, hypoxemia (i.e., low blood oxygen
levels), markers of a low blood pH (metabolic acidosis), and fluid
sequestration.

This scoring system aims to predict the severity of acute

pancreatitis by determining if there are any signs
of dehydration (e.g., high BUN), inflammation (e.g., high WBC
and LDH), or organ dysfunction (e.g., hypoxemia) as well as the
ability of the pancreas to regulate glucose levels (e.g., presence
of hyperglycemia).

A Ranson score of 0 or 1 predicts that complications will not

develop and that mortality will be negligible. A score of 3 or
greater predicts severe acute pancreatitis and possible mortality.
Severe acute pancreatitis is defined by the presence of any organ
failure or local pancreatic complications such as pseudocyst,
abscess, or necrosis.
SCRIPT FOR ATLANTA CRITERIA
The Atlanta Classification of acute pancreatitis (AP) is widely
accepted and has been used by physicians and radiologists since
1992. It is revised in 2008. Using the Atlanta criteria, acute
pancreatitis is diagnosed when a patient presents with two of
three findings, including abdominal pain suggestive of pancreatitis,
serum amylase and/or lipase levels at least three times the
normal level, and characteristic findings on imaging. The Revised
Atlanta Classification identifies 4 severity of Acute Pancreatitis:
During the 1st week of onset of signs & symptoms we have Non-
Severe AP & Severe SP

 Non-Severe AP – there is an absence of organ failure or if

there is a presence of organ failure, it should not exceed 48
hours in duration.
 Meanwhile, the Severe AP- has the hallmark of persistent o
patuloy na organ failure which exceeds 48 hours in duration.
The 3 organ systems that are closely monitored are
Respiratory, Renal, and Cardiovascular systems. If at least
1 of these organ systems are compromised, the medical
treatment is adjusted.

After the 1st week of onset of signs and symptoms, the 2

classifications are as follows: Interstitial Edematous Pancreatitis
(IEP) & Necrotizing Pancreatitis.
In Interstitial Edematous Pancreatitis or IEP, there is a fluid
accumulation between an organ and another organ or an organ’s
protective membrane and the organ itself while the pancreas is
inflamed which can be seen on CECT or Contrast-Enhanced
Computed Tomography or commonly known as CT Scan. While
the Necrotizing pancreatitis includes the necrosis of the pancreas
alone, or the peripancreatic tissues/ tissues surrounding the
pancreas alone, or both pancreas and peripancreatic tissues. The
necrosis is further divided into 2: sterile(which is the absence of
proven infection in necrosis) or infected (which means either
there are gas bubbles seen on CT scan result, there is a positive
culture obtained by image -guided fine-needle aspiration, or a
positive-culture obtained during the 1st drainage or necrosectomy.
5. What are the potential complications of acute
pancreatitis?

So again, to briefly discuss lang ulit what is acute

pancreatitis, isa po siyang condition kung saan may
pamamaga na nangyayari sa pancreas ng isang tao.
Nagreresult ito sa maagang pagactivate ng mga digestive
enzymes na nirerelease ng pancreas to break down food,
habang nasa loob palang sila mismo ng pancreas  na
nagca-cause para madamage or mairritate yung tissues
ng pancreas at maginflamed. Another term for this is
called autodigestion. And if not treated early at tama,
serious complications may arise kagaya ng:

 First, magiging prone to infections yung mga patients

na merong acute pancreatitis na condition mainly
because may problem sa pancreas nila, hindi ito nag
ffunction ng ayos and may inflammation na
nakakapagpaweaken at damage dito. So, sa mga tao
who experience acute pancreatitis are more likely to
develop complication wherein yung pancreas ay hindi
makakatanggap ng tamang blood supply na kailangan
niya sa katawan that could cause for the tissues of the
organ to die or necrosis. Dangerous ito kasi once
mainfect yung pancreas pwede ito maglead to an organ
failure kaya kailangan nito ng tamang paggamot at
agaran to avoid further complications or even death.
 Meron din tayong tinatawag na pseudocysts, pseudo
means “false” kaya this is not a true cyst na dapat
makaalarma ng sobra sa patiente. Benign siya at na
nafform due to the collected leakage of pancreatic
enzymes or fluid mula sa pamamaga ng pancreas. So
unlike a true cyst, may lining yung structure non
kumpara sa pseudocyst na wala. The most important
factor lang na kailangan bantayan at maiwasan ng
pasyente mangyari is yung pag rupture ng pseudocyst
lalo na if malaki ito, kasi it can cause serious
complications such as internal bleeding, infections and
death.

 So, the pancreas truly helps us in maintaining good

health. It not only secretes digestive enzymes na
kailangan natin for complete digestion of foods and
absorption ng nutrients. Itong pancreas din ay
nagrerelease ng Insulin ang glucagon hormones that
stabilizes our blood sugar. So, kapag ang isang
patiente ay may acute pancreatitis it is not unlikely for
him to develop diabetes kapag tumagal at di naagapan,
kasi again, ang pagkakaron ng inflammation can
damage the pancreas and its cell. Thus, abnormalities
sapag produce ng Insulin and glucagon sa katawan ng
pancreas ay maglelead to diabetes.
 A.R.D.S or acute respiratory distress syndrome ay isa
rin sa mga complications na pwede makuha ng isang
patient na nagssuffer from acute pancreatitis. Dahil
again, pag may ganitong condition ang isang tao,
meron siyang pamamaga sa pancreas. Kaya as our
body’s response to inflammation, merong mga
inflammatory chemicals na marerelease sa blood
stream natin na nag ttrigger for different body parts to
react and mamaga rin including the lungs. Kasabay
nito, yung mga alveoli ng lungs can also get inflamed
and be filled with water na nagccause for the patient to
acquire breathing difficulties and lower oxygen levels.

 Renal failure, ay isa rin sa mga complications na maari

matamo ng patient with acute pancreatitis which is in
relation to a lowered oxygen level of the body,
maapektuhan nito yung buong state ng well-being
natin kasi we cannot live without oxygen and so is our
organs and isa sa pinakaapektado rin kapag bumaba
ang oxygen levels natin ay ang heart and our kidneys
or yung process ng renal circulation nito na kapag di
maagapan can also lead to dialysis na kung iisipin natin
mas magpapaburden lalo sa patiente who’s already
suffering from acute pancreatitis.
 Malnutrition could also be a complication with acute
pancreatitis kasi meron ngang abnormalities na hindi
nakakapag secrete ng ayos ng digestive enzymes ang
pancreas, that results to indigestion and malabsorption
of nutrients in the body.

 Lastly, kapag pinabayaan natin yung inflammation ng

pancreas for a very long time at pabalik balik lang ito,
based on research, it can increase yung risk na
madevelop ito into cancer.

6. Historically, the patient with acute pancreatitis

was made NPO. Why?

Before anything else, let’s talk about NPO muna. So, this
is an acronym which stands for nil per os, or in layman’s
term is nothing by mouth. Basically, marami rin po kasing
cinonsider para lang magcame up ang mga medical
practitioners sa kanilang admission orders that Mr. JM
shouldn’t continue the normal route of feeding. So,
siyempre, priority pa rin po ‘yung better management
natin to at least lessen the signs and symptoms brought
by the pancreatitis.
Here are the things which naging rationale or logical
reason ng mga practitioners to still provide nutrition to Mr.
JM, even though totally nang nothing by mouth:

 First, we all know that the stomach and intestine are

all supported by the accessory organs such as the
pancreas, liver, and gallbladder. Since they are also
part of the digestive system, anything na may food
or water na icoconsume ‘yung individual, the body’s
natural response is of course, absorb, digest, and
produce the needed enzymes. Based on the
anatomy rin ng pancreas, it lies sa upper abdomen
which is nasa likuran ng stomach. Everytime na may
presence of food sa stomach, automatically the
pancreas is secreting enzymes that will breakdown
the macronutrients; these enzymes are amylases,
lipases, and proteases. It’s one of the contributing
risks din kaya nakaeencounter si patient ng extreme
abdominal pain. So, they decided na instead of
feeding the patient orally, other routes of feeding na
lang ‘yung iaadminister to let the pancreas rest kasi
mas maaaggravate lang ‘yung symptoms na
nararamdaman niya.

 As mentioned, based din sa admission history and

physical examination, he had abdominal pain,
 nausea, and vomiting several days ago; presence
rin ng rebounding which the release of pressure
from abdominal is mas masakit or giving discomfort
feeling than application of pressure, or ‘yung
pagpindot sa tiyan. One thing din, they noticed na
nagkaroon ng hypoactive bowel sounds. Actually,
very crucial ‘yung bowel sounds since it is a sign na
normal ‘yung intestinal activity. So, they confirmed
na may soft and low abdominal sounds lang in Mr.
JM’s 4 quadrants. Based on the studies, whenever
na may hypoactive bowel sound, reason may be an
ileus or hypomotility ng GI tract though wala naman
talagang blockage, others din, they say na
hypoactive bowel sounds may also be caused by
obstruction to the proper flow of the food, since the
sounds are the by-product din ng digestion.

These factors po ‘yung mga naging barrier para

magprovide ng nutrition support kay patient through oral
feeding. Luckily, there are other ways pa rin naman to
supply the nutrients na needed ni patient for faster
recovery, it’s either enteral or parenteral which we will
discuss later on. Mababago lang ‘yung current nutrition
management if na-reduce na ‘yung episodes of nausea,
vomiting, and intense abdominal painsince we want to
lessen the damage it may bring if ipipilit natin ‘yung oral
feeding.
7. The physician has written an order for a nutrition
consult. Using the most current literature
and ASPEN guidelines, explain the role of enteral
feeding in acute pancreatitis. Do you agree
with the initiation of enteral feeding? Why or why
not?

Sa pagbibigay po ng isang effective na recommendation

para sa isang pasyente kagaya ni Mr. JM who is suffering
from a disease, madami po tayong factors na kailangan
iconsider dahil syempre ang nutrition po plays a very
important role para sa pagpapagaling ng tao. Based on
our research about the current literature and ASPEN
guidelines na available online, nakita po namin na for
patients with acute pancreatitis, enteral nutrition is best
given. Dahil with enteral nutrition daw po compared to
parental nutrition, mas mababa po yung mortality rate
and yung possibility na magkaron ng complications. At
napatunayan po ito mula sa mga pasiyente with acute
pancreatitis na nagunderwent with this kind of nutrition
support.

And so, to answer the question po, yes. We agree with the
initiation of enteral feeding for the patient since naka
nothing by mouth yung pasyente, kailangan parin natin
maghanap ng other effective method para masustain yung
life and ma meet yung daily nutrient requirements niya at
mapprovide po ito ng enteral nutrition. Another benefit po
kasi ng feeding method na ito sa pasiyente is it prevent
yung pagbreakdown ng mucosal barrier natin sa gut at
maiwasan yung bacterial translocation. Nagagawa po ito
ng enteral feeding kasi with this nutrition support diba
naka liquid form yung foods na dadaan sa tube mula sa
nose papunta sa ating gut and with that, nasstimulate ng
EN formulas yung digestive motility natin. Kasi diba yung
gut natin may mga present microorganism talaga dyan na
tumutulong in digestion and so, kapag nastuck lang yung
intestine natin na walang dumadaloy na food or any fluid
maaring maperforate nitong mga organism na ito yung
mucosal barrier ng tiyan natin at mag start magkaron ng
bacterial translocation meaning, yung mga viable
microorganism ng G.I natin ay kakalat sa extraintestinal
natin na makakapag resulta to a widespread infections,
complications or sepsis which is the body’s extreme
response to an infection. Lalo na at may inflammation sa
pancreas mas madali ito maapektuhan. Additionally,
based on our research din po it is better daw po if yung
route ng enteral nutrition natin for acute pancreatitis
patients is from the nose down to the jejunum kasi if sa
stomach daw po mageend yung tube ma-sstimulate pa
nito yung pancreas para magproduce ng mga enzymes na
lalo magpapasakit pa sa nararamdaman nung patient
since the pancreas is located just behind the stomach.
That being said, kailangan padin po natin iclosely monitor
yung patient to ensure na yung intervention na ginawa is
working properly.

8. If you have recommended enteral feeding, does

this patient’s case indicate the use of an
immune-modulating formula?

First of all, yung immune-modulating formulas po are a

kind of supplement na tumutulong po para ma-enhance or
ma-restore yung normal function ng isang weakened
immune system due to a disease or any medical
procedures such as yung mga surgeries or even mga
chemotherapies. Itong immune-modulating formulas are
consisted po of arginine, glutamine, nucleic acids, and
omega 3 fatty acids na essential para mapalakas ang
immune system response ng tao. So, kagaya po ng ibang
intervention, bago ka magsimula kailangan mo muna
maging sigurado with the condition of the patient bago
magbigay ng kahit anong gamot or supplementation kasi
maaring magkaroon ng adverse effect ang mga ito at
magbunga lalo ng problema. And so, kung titignan po
natin yung laboratory results ni patient specifically his
White blood cells count and yung neutrophil niya makikita
natin na mataas yung value nito compared sa normal level.
Hence, yung elevated WBC and neutrophil count ni patient
ay sign that his immune system is responding to the
disease at hindi na nangangailangan pa for added
supplementation like immune-modulating formulas. Kasi
ang mga in need lang daw po ng immune-modulating
formulas based on our research, ay ang mga patients who
are leukopenia or may mababang white blood cells na
wala masyadong kakayahan to fight off infection or the
disease. Another information that we found online din po
is kapag ang isang pasyente with acute pancreatitis ay
nabigyan ng enteral nutrition/feeding within the first 24-
48 hours niyang nasa hospital ay potentially may effect po
ito to modulate his immune system response na kung
babalikan po natin sa given, he’s only been hospitalize for
48 hours kaya pasok parin po ito and maaari po
magbenefit dito yung immune system ni patient lalo na
kung tama daw po yung placement ng tube sa kanya for
proper absorption of nutrients narin po ng katawan niya.

9. Assess Mr. JM’s height and weight. Calculate his

BMI and % usual body weight.

Para naman po ma calculate yung sa BMI at percent usual

body weight inuna po munang icompute yung height at
cinonvert into inches bali yung 5 itinimes sa 12 kaya
nakuha yung 60 at iplinus yung 60 sa 11 kaya nakuha
yung 71 inches. After po non ay itinimes siya sa 0.0254 at
ang total ay 1.8034 na kung saan kakailanganin mamaya
para sa height m2 sa BMI. After nung sa height yung
weight naman po bali cinonvert yung pounds into kg na
kakailanganin din po para sa BMI bali yung 245 na weight
mismo nung patient ay ididivide sa 2.2 kaya nakuha yung
answer na 111 kg.

After po ng conversion kukunin na natin yung percent

Usual Body weight ni patient bali yung 245 na current
body weight ay imaminus sa na ain na weight ni patient
which is yung 50 at ang total ay 195 lbs at after non
ididivide na si 245 sa 195 at itataimes sa 100 kaya ang
total ng usual body weight percent ni patient ay 125.6%

Pagkatapos saka naman dadako sa BMI ali ang formula po

niya ay weight (kg) divided by height (m2) bali yung
cinonvert natin kanina sa weight which ang total ay 111kg
ay ididivide sa 1.8034 raise to 2 ay ang total ay 34.13 at
based po sa WHO asia pacific ang 34.13 ay katumbas ng
Obese Type 2.

10. Evaluate Mr. JM’s initial nursing assessment.

What important factors noted in his nutrition
assessment will affect your nutrition
recommendations?

On Mr. JM nursing assessment sa abdominal appearance

niya it is exposed that he is in obee condition since nag
gained siya ng 50 lbs over the last 5 years, Para naman sa
abdomen palpation niya. Nakitaan na merong tense
surface. For his bowel function naman it indicates that it
continent at isa itong good sign dahil si patient ay kaya
niya pang icontol ang kanyang bowel. However, sa
kaniyang bowel sounds it is stated a P, hydro which
connotes present pero mahina yung sound. As a
recommendation, yung mga pagkain na magpapalala ng
gas production katulad ng beans, lentils, corn, pasta,
potatoes at other starchy foods ay kailangan iavoid ni
patient.

For patient’s nutrition assessment, yung excessive intake

niya sa alcohol, constant vomiting and nausea at yung
weight gain niya over the last 5 years ay magkakaroon ng
impact sa nutritional management niya. The vomiting and
nausea will affect our recommendations dahil impotante to
keep in our minds na mahirap para kay Mr. JM na kumain
and keep the food down. Para ma achieve at ma establish
yung proper weight goal para sa kaniya we will
recommend to him na bawasan ang kaniyang caloric
intake while also intervening his current condition. Yung
kaniyang food history din napansin namin na masyado
siyang mahilig sa fatty foods na may combination ng pag
inom ng alak. Kaya naman we will also recommend na
magsisimula siya sa pagkain ng three meals with two
snacks per day at dapat mag concentrate siya sa pagkain
ng whole grains, fruits and vegetables like cucumber,
lettuce or spinach. At sa pag inom ng alak Unti-unting
pagtanggal ng mga alcoholic beverage tulad ng beer,
bourbon, wine at iba pang other mixed drinks ay dapat
iobserved at imonitor dahil ito ay makakatulong para
mabawasan or maibsan yung mga sintomas na
nararamdaman niya and it will also reduce his
hospitalization.

11. Determine Mr. JM’s energy and protein

requirements. Explain the rationale for the method
you used to calculate these requirements.

Dito naman sa no. 11 para makuha yung energy at

protein req. Inuna munang icompute yung DBW ni patient
(ididictate na lang yung computation na nagawa) at ang
total ng DBW ay 72 kg after ma compute nung DBW ang
next ay ang TER para makuha yung total energy
requirement ni patient dapat I mumultiply yung 72 na
dbw niya sa PAL ni patient which 35 since light physical
activity lang naman ang ginagawa niya at ang total nung
kaniyang TER ay 2500 kcal/day

After ng kaniyang TER ang next naman na icocompute ay

ang protein req. ni patient According to espen guidelines
on nutrition in acute pancreatitis ang total ng protein
requirement sa isang patient na may acute pancreatitis ay
1.2 -1.5 g/kg/day. Bali yung DBW ni patient na 72 ay
itatimes sila sa protein req. Ng acute pancreatitis for lower
range ang total ay 86.4 g at for upper ranger ay 108 g. at
kaya po namin ginamit itong computation is beacause ito
po yung common computation for TER calcuation. At a
protein requirement naman po we use the upper range
dahil the higher the protein intake can help the patient to
ease abdominal pain from pancreatitis and nakakatulong
din ito para ma reduce yung risk ng kaniyang future
attacks. Although there is an increased urea production
rate in patients receiving a high protein diet (more than
1.5g protein/kg/d), this regimen might ensure that a
positive protein balance can be achieved. According to
ESPEN guidelines on nutrition in acute pancreatitis.

12. Determine Mr. JM’s fluid requirements. Compare

this with the information on the
intake/output record.
To determine po yung fluid requirements ni Mr. JM ang
ginamit po namin is his total energy requirements para
hindi po masyadong malayo sa energy intake niya. 35
ml/Kg is yung baseline po ng fluid requirement for adults
tinimes po siya sa 111 kg which is yung weight po ni Mr.
JM ang total po niya is 3,890 ml.

To compare naman po yung intake and output record ni

Patient 4,500 ml/kg po yung fluid intake niya pero mas
mataas padin yung output niya na 4,879 ml/kg so ibig
sabihin po yung renal function niya is working so pwede
po increase yung fluid requirement niya from 30-35 ml/kg
para maiwasan po yung dehydration.

13. From the nutrition history, assess Mr. JM’s

alcohol intake. What is his average caloric intake
from alcohol each day using the information that he
provided to you?

According po sa nutrition history ni Mr. JM umiinom siya

ng six- pack of beers and 4-5 shots ng bourbon daily and
tuwing weekends naan daw po bukod sa beer, bourbon
umiinom din siya ng wine and other mixed drinks po.
Gamit poo yung information na binigay ni Mr. MJ we were
able to compute his average beverage caloric intake. So
yung 6-packs po ng beer ang equivalent po niya is 924
Kcal/day and 400-500 Kcals naman po from bourbon
shots per day. Inadd po yung total ng beer and bourbon
shot so ang lumabas po na total non is 1,350 Kcal/ day
since tuwing weekend bukod sa beer and bourbon
umiinom din siya ng wine and other mixed drinks yung
computed na total caloric intake niya might be greater po.

14. List all medications that Mr. JM is receiving.

Determine the action of each medication and
identify any drug–nutrient interactions that you
should monitor.

One of the admission orders kasi kay Mr. JM is to provide

medications, generally para ma-treat ‘yung current
condition niya which is again, the Acute Pancreatitis.
Categorized ‘to sa mga medications na binigay sa kaniya
in a fixed time, or naka-schedule talaga, or PRN or pro re
nata, meaning taken lang when needed na talaga. This
time, we will discuss the medications and its action and
nutrient interaction

 Imipenem
Taken: 1000 miligram every 6 hours
Action: This drug has an antimicrobial activity, esp. Sa
mga gram-negative such as ‘yung Pseudomonas
aeruginosa and the Enterococcus and gram-positive
aerobic and anaerobic bacteria, and even sa mga
multi-resistant microorganism which ito ‘yung type na
they tend to resist on the drugs na dapat sana is
papatay sa ‘kanila. So how come na they have the
ability to lowers the microbial activity? The answer on
this po is that, they prevents or inhibits the cell wall
synthesis of such bacteria through binding to PBPs or
penicillin-binding proteins. Study showns din po na
‘yung drug na ‘to isn’t properly absorb sa GIT, hence,
inaadminister ito parenterally, 89% is through
intramuscular (IM) injection. But remember that too
much consumption of this can lead to infusion-related
effects, gastrointestinal disturbances, rash, and
seizures naman in regards to the central nervous
system.
Drug-Nutrient Interaction: If consumed daw po
together with other drug na cine-carry out din kay
patient like the Lorazepam, nababawasan ‘yung natural
efficacy ng drug na ito. ‘Yung amount din daw po ng
nutrients such as folic acid, potassium, Vitamin B2,
Vitamin B6, Vitamin B12, Vitamin C, and Vitamin K are
begin to become less. Hence, ask the physician din if
it’s recommended na magsupplement to fill in the said
amount.

 Famotidine
Taken: 20 miligram IVP every 12 hours
Action: It’s a drug under H2 receptor antagonist,
where nililimit niya ‘yung acid production ng from the
parietal cells ng gastric mucosa, which nalelessen
yung possibilities to have GERD and Zollinger-Ellison
Syndrome, along with its symptoms. Meron kasing
neuroendocrine cells na close sa parietal cells
which ito ‘yung nagreregulate ng histamine secretion.
Once histamine is release, magkakaroon ng messenger
to activate the proton pumps sa parietal cells, kaya
magrerelease nang magrerelease yan ng proton which
will increase the acid secretion. Kaya, famotidine is
an antagonist or blocker kumbaga in action of
histamine.
Drug-Nutrient Interaction: So, based on studies din,
the Famotidine may be a caused din daw sa increase of
serum ALT levels. Mentioned earlier, ‘yung
Acetaminophen requires gastric acid to be absorbed, so
may contraindications siya in taking Famotidine
which reduces the gastric acid production. Some foods
din such as the caffeine and alcohol increase the
instances of a gastric irritation. Since, acidic talaga
mga foods na ‘to, kumokontra siya sa state ni stomach
na less acid, kaya it becomes triggering factor na
pwedeng magrelease ng acid si stomach as well.

 Meperidine
Taken: 50–150 mg IV every 3 hrs prn or as needed
lang talaga
Action: The Meperidine naman is a type of drug na
narcotic analgesic or pain killer, pain medication. It is
the same with the morphine na it communicates with
the nerves and brain to ease the moderate- to severe-
pain. The difference between the two lang are:
Meperidine produce less smooth muscle spasms,
constipation, and depression than sa morphine drug.
However, ‘yung onset ng action ng Meperdine is quick
pero ‘yung duration ng effects is kind of short lang
din. In terms of the body’s absorption, less than
half as effective kapag iniinduct orally compared to
parenteral administration, so again, it is injected
intravenously.
Drug-Nutrient Interaction: Again, when combined
with other drugs na binibigay kay patient such as the
Docusate Sodium, Magnesium Hydroxide, Lorazepam,
and Ondansetron, adverse effects may be seen. In
addition, pwede too much ingestion of this can lead
to constipation, e since iniiwasan nga natin ito because
we want na magkaroon si Mr. JM ng noral intestinal
movement or activity. Dietary fiber and also water
requirement must be adjusted.

 Ondasetron
Taken: 2–4 miligram IV every 4–6 hrs pro re nata
Action: It’s an antagonist of serotonin 5-HT3 receptor
which helps to prevent the episodes of nausea and
vomiting na 2 of the chief complaints ni Mr. JM. The
vomiting din kasi may be caused of one of the drugs na
tinetake ni patient, which is the Imipenem since often
times kasi may mix na itong cisplatin which damages
the GI tract and causes calcium dependent exocytic
release of 5-hydroxytryptamine (HT)3 from
enterochromaffin cells sa GI mucosa. ‘Yung serotonin
5-HT3 receptor kasi is nakalocate siya sa nerve
terminals ng vagus which longest nerve ng autonomic
nervous system in the body and centrally in the
chemoreceptor trigger zone of the area postrem. ‘Yung
relationship between the emetogenic action ng mga
natural agent na nasa drug na nakaka-nausea and
vomit and the release of the said serotonin from the
enterochromaffin cells of the small intestine by causing
degenerative changes sa GI tract. The production of
the 5-HT3 binds to its receptors on the vagal and
splanchnic nerve receptors that will now project ‘yung
medullary vomiting center, that will cause nausea and
vomiting. Thus, ‘yung antiemetic effect of
Ondansetron is probably due sa selective antagonism
of 5-HT3 receptors na again located in either the
peripheral or central nervous systems, or both. The
single dose of this drug had no effect sa motility ng
esophagus and stomach, lower esophageal sphincter
pressure, or small intestinal transit time
Drug-Nutrient Interaction: It can be taken with or
without food. However, when administered together
with medications such as Lorazepam and Meperdine,
some adverse effects may be seen.

 Docusate Sodium
Taken: 100 miligrams po (per os or by mouth) two
times daily pro re nata, if no bowel movement. Why is
it being conducted to the patient?
Action: Under siya ng laxatives which treated the
constipation condition; o, ‘yung sodium content of the
said drug attracts water and even fats that result to a
softer stool. As, we all know for the fact na mayro’n
nga siyang hypoactive bowel movement, we want this
drug na iadminister to of course, maging back to
normal na ‘yung intestinal activity ng patient.
Drug-Nutrient Interaction: ‘Pag daw ginagamit ‘to
for a long period of time, narereduce yung
magnesium while increase the potassium in the stool
output. Since, ‘yung effect daw kasi ni Docusate is
commonly naproprocess sa jejunum part, sa
concentration kasi na ‘to mas secreted mostly ‘yung
water, fats, sodium, and even potassium. Kaya
proof ‘yun na na in content of stool, mataas potassium
levels.
 Magnesium Hydroxide
Taken: 30 miligram per os daily pro re nata
Action: Magnesium Hydroxide naman po is an
inorganic compound na may dual effect—laxative and
antacid. When ingested, it will enter the stomach. But
its effects will varies on the amount of the suspension
na naingest which as mentioned earlier, can be act as a
laxative or antacid. For the adults po, from 0.5 - 1.5
grams, the said drug will act as an acid neutralizer sa
stomach. ‘Yung hydroxide ions from the Magnesium
Hydroxide will be mixed sa acidic H+ ng HCL acid
which is made by the stomach’s parietal cells. This
process will result to the formation of Magnesium
Chloride and water. On the other hand, a drug
ingestion from 2 to 5 grams, it will act as an laxative in
the colon. The majority of the suspension is not
absorbed in the intestinal tract and as a result it will
have an osmotic effect which nagdra-draw ng water
from the surrounding tissues to the gut. These effects
still stimulate intestinal motility and as it is a laxative
nga, of course, will have the urge na to defecate. The
drug will also release cholecystokinin (CKK) na
hormone rin sa intestine which will accumulate water
and electrolytes in the lumen.
Drug-Nutrient Interaction: Sa other drugs naman po,
it has interaction din since nababawasan ‘yung proper
 absorption nila like the Aluminum Hydroxide,
Penicallamine, Bisphosphates, Ketoconazole,
Quinolones or Tetracyclin; even din sa mga nutrients
such as Folic Acid and Dietary Iron. In contrast, it
ehances naman the absorption of Ibuprofen which one
of the NSAIDs.

 Lorazepam
Taken: 0.5–1 mg per os every 8 hours as needed lang
Action: For the last drug named, Lorazepam. It is a
short-acting benzodiazepine that communicates with
the central nervous system in order to lowers the
brain’s activity and function. Inaadminister ito to at
least magkaroon ng relief sa anxiety and depressive
symptoms and disorders.
Drug-Nutrient Interaction: If currently na tinetake
ito, it’s better to avoid the consumption of alcohol and
caffeine-containing foods. Other drugs din na iniinom ni
patient like the Imipenem and Meperidine, when
combined sa Lorazepam, could have an adverse effects.
Sa Magnesium Hydroxide naman, it inhibits the
excretion sana ng magnesium.

15. Identify at least 3 of the most pertinent

nutrition problems and the corresponding nutrition
diagnoses.
Yung first na nutrition problem na nakita namin is yung
kanyang excessive alcohol intake habang patagal ng
patagal, sinabi din dito ni Mr. JM na sinusubukan nyang
ihinto yung pag take nya ng anti-depressant medication
and because of this hindi na nya namalayan na nag
increase na yung intake nya ng alcohol.

2nd na aming na identify na nutrition problem is yung

kanyang pagiging obesity, makikita sa patient history na
sya ay isang doctoral student habang sya ay nag
tatrabaho alam naman natin kung gano kahirap ang
pagiging med student. At dahil sa kanyang busy schedule
nawalan na sya ng time magkaroon ng physical activity.

Yung last na nutrition problem na aming nakita is yung

kanyang undesirable food choice, dahil nga din sa busy
schedule nya wala na syang time makapag prepare ng
healthy foods kaya madalas ang kinakain nya is yung mga
pagkain sa labas or mga fastfoods .

16. Write your PES statement for each nutrition

problem.

For the PES na nabuo name are the following:

First is the excessive alcochol intake with the contributing
factor or etiology of depression and sa pag quit nya ng
medication nya dito, dahil sa pag try nya mag stop ng
medication dinya na namalayan na nag increase yung
intake nya ng alcohol. it is evidenced by the patient
history po ng kanyang drinking pattern na 6 pack of beer,
4-5 shots bourbon daily saka sa weekends umiinom sya
ng beer, bourbon, wine and other mixed drinks.

For the second diagnosis po we have obesity which is

related po sa kanyang busy schedule sa kanyang study at
kanyang trabaho and dahil po dito nwalan na sya ng time
para mag conduct ng physical activity para ma maintain
yung kanyang timbang.

Lastly po is yung Undesirable food choices ni mr JM

related to also sa kanyang busy schedule wala na syang
time makapag prepare ng healthy meals sa araw araw
kaya ang madalas nyang kainin is yung mga pagkain sa
labas katulad ng coffee at breakfast with a bagel or
toast—lunch is usually a sub sandwich or pizza.

17. Determine your enteral feeding

recommendations for Mr. JM. Provide a formula
choice, goal rate, and instructions for initiation and
advancement.
 Mr JM diagnosed of having a acute pancreatitis and
the admission order for his diet was NPO stands for “Nil
per Os” or Nothing by mouth. So the option for his
nutrition support is either Enteral nutrition or Parenteral
nutrition for sustaining his nutritional needs.

According to ESPEN guidelines, in patient with acute

pancreatitis and inability to feed orally, Enteral nutrition
is preferred kaysa sa Parenteral nutrition because EN is
supposed to preserve the gut mucosa, stimulate intestinal
motility, prevent bacterial overgrowth and increase the
splanhnic blood flow ng patient. Therefore, the
recommendation for the Enteral Nutrition kay Mr. JM, ang
route of feeding for EN will be at the Nasojejunal feeding
because NJ tube feeding is preferred para it allowed for
bypassing the inflamed pancreas and resting organ kasi
diba ang ating main goal for managing the nutrition
therapy for the patient na may condition with acute
pancreatitis is ma-put at-rest yung kaniyang pancreas at
maibsan yung inflammation ng kaniyang pancreas. In
addition, we recommend the NJ tube feeding dahil low risk
maka-develop ng aspiration kasya sa Nasogastric tube
feeding na may potential na magkaroon ng high-risk of
pulmonary aspiration.

For the EN formulation naman, we recommend the

peptide based formula is a type of hydrolyzed formula that
is categorize of semi-elemental formula. We recommend
this formula because semi-elemental formulas is magiging
less ang pancreatic stimulation, less din yung digestion ni
patient and readily absorbed into small intestine dahil ang
route of feeding natin ay NJ tube so yung end-point is
nasa jejunum na kaya we recommend this formula.

The instruction for initiation naman to insertion of

Nasojejunal tube to the patient, the attending physician or
nurse will give a medication to help the patient relax while
the tube is being inserted. Insert the tube into the nostril
of the patient and once the tube is into the stomach (60
cm) the patient is turned onto their right side before the
tube is advanced a further 10 cm. To make sure the NJ
tube is in the right place will take a look at the x-ray and
adjust the position of the tube if necessary. Lastly, the
tube will tape securely to the nose and cheek of the
patient.

Ang peptide based formula na ibibigay sa patient is

the Nestle Peptamen brand, the goal rate ay Peptamen at
100 mL/hr. That will start at 20mL/hr, titrate by 10-20
mL/hr every 4 hours to goal. This will provide 2520 kcal,
and 126 grams of protein. For his total fluid intake will be
2400mL. Kailangan imonitor si patient every 4 hours if
natotolarate ba ni patient yung amount recommended sa
kaniya or hindi. If hindi niya natotolarate kailangan natin
baguhin young amount recommended and yung rate of
infusion kay patient na hanggang matolerate niya ito.

18. What recommendations can you make to the

patient’s critical care team to help improve
tolerance to the enteral feeding?

When early enteral nutrition administer to the patient,

kailangan natin mamonitor or icheck si patient every 4
hours para ma-examine natin if kaya ba ni patient yung
EN feeding na binigay sa kaniya at kung may mga
complication such as yung vomitng, abdominal pain and
diarrhea. Kaya habang maaga pa kailangan natin ito ma-
address agad para makatulong ito sa pag-improve niya ng
tolerance for enteral feeding at para mapalitan natin kung
kinakailangn yung binigay na amount and fomula na EN
kay patient.

 Next, to help improve the tolerance of the patient to

the enteral feeding is kung possible kailangan natin
magstart at slow rate of feeding and change the
feeding method to continuous feeding para maprevent
natin yung mga EN complication nga such as vomiting,
abdominal pain, diarrhea, and constipation sa patient.
Kasi if the feeding method natin is Intermittent or
Bolus intermittent baka hindi matolerate ni patient
 yung high amount of feeding na binigay sa kaniya at
may potential na high risk of having vomiting,
abdominal pain, diarrhea, and constipation si patient.

 Third, administration of Prokinetic agents, ang

prokinetic agents po kasi is a type of drug na kaya
maka-enchance ng gastrointestinal motility ng patient
by increasing the frequency or strength of contractions
na pwedeng makatulong sa pag-improve ng tolerance
ni patient for enteral feeding administration. Also,
prokinetic agents is effective din sa mga patients na
high risk of aspiration and for those with intolerance to
gastric EN. But administration of prokinetic agents na
dapat be mindful tayo na may mga adverse
complication nito na dapat maexamine muna ang
patient if pwede siyang take ng mga gantong klase
drugs.

 Lastly, if the patient is hindi niya na talaga kaya

matolerate yung binibgay sa kaniyang EN formula is
kailangan natin magchange to Parenteral nutrition or
combination muna ng EN and PN if possible kung
matotolerate ni patient yung gantong nutrition support
para makhelp for his tolerance.
19. List factors that you would monitor to assess
tolerance and adequacy of nutrition support.

Factors na kailangan natin for monitoring to assess yung

tolerance and adequacy of nutrition support ng patient are
the following;

 One of the factors na kailangan natin monitor when

assessing the tolerance and adequacy of nutrition
support ni patient ay yung kanyang bowel sound ng GI
tract. If may bowels sound sa GI tract ni patient ang
indication is natotolarate niya yung EN
recommendation sa kaniya na gumamana na yung
kaniyang GI tract.

 Second the we need to monitor is the Gastric Residual

volumes na kailangan natin check frequently kapag
naka enteral feeding si patient. Gastric residual volume
or GRV is the amount of gastric contents found in the
stomach at a single point in time. Para monitor it is,
gagamit yung clinicain ng catheter tip syringe with
plunger na icoconect niya sa feeding tube ng patient
and then hihilain yung plunger to extract whatever is in
the stomach. This is repeated until no contents are
produce and then the total volume of the extracted
contents is measured in milliliters. Kung ang nakuhang
 GRV sa patient is nasa safe amount or measurement
ay yung contents is will reinserted and tube feeding
continues. Pero if the GRV is hindi nasa safe
measurement is yung nakuhang content sa patient ay
ididiscard and the tube feeding ay stop muna until the
GRV decreases to the safe level. So the current
recommendation to monitor the GRV ng patient is
every four hours during the first 48 hours ng pagkabit
ng tube feeding kay patient. According to ASPEN the
guidelines for nutrition support in patients who are
critically ill EN should not be stopped for a GRV of less
than 500 mL unless there are other signs of feeding
intolerance. GRVs ranging from 200 to 500 mL should
prompt clinicians to implement methods to reduce
aspiration risk.

 Third na kailangan natin mamonitor ay if the patient

having abdominal distention and/or discomfort na baka
caused ito ng constipation or build-up of gas or
gastrointestinal obstruction sa patient na kaya the
tolerance ng patient sa EN ay hindi sapat, kaya dapat
we need to check the bowel function and kailangan
ma-minimize natin yung air na pumapasok sa feeding
tube kaya nagcaused ng discomfort sa patient na
nagiging hindrance to achieve the EN goals for the
patient. At dahil din sa volume, rate and concentration
of the feeding ni patient kaya nakaka-experience siya
 ng abdominal pain, na hindi pala tama yung bininigay
sa kaniyang amount of feeding regimen na hindi niya
natotolerate.

 Lastly na kailangan natin mamonitor if the patient is

experiencing nausea and vomiting, so to prevent the
nausea and vomiting ni patient kailangan naka sit
upright or at a minimum of 30 to 45 degress angle
habang in feeding si patient. We need to assess also
the feeding regimen nga ni patient including the
method of feeding, volume, rate, and concentration of
feed na baka ito ang nagcaused kay patient na nausea
and vomiting na kaya hindi niya matolerate and we
need to check the position of the feeding tube baka na
wala na siya sa position kaya nagcaused din kay
patient ng nausea and vomiting.

20. If this patient’s acute pancreatitis resolves,

what will be the recommendations for him
regarding nutrition and his alcohol intake when he
is discharged?

If the patient’s resolves here are some of the

recommendations for the patient for him regarding to his
nutrition and alcohol intake. Since ang patient ay may
acute pancreatitis in which the risk factor ay binge
drinking of alcohol, alcohol can sensitize the pancreas to
damage. Alcohol is believed to cause precipitation and
increase the viscosity of pancreatic secretions, which
causes protein blockages in the small ducts to form calculi,
causing inflammation and fibrosis. It causes the patient
pancreas to produce toxic substances that leading him to
an acute pancreatitis. Advise him to refrained from
drinking alcohol.

Caffeine containing drinks must be limited because it

might make symptoms worse, patient should avoid or
limit any beverage that contains caffeine, a mild to
moderate stimulant. This includes coffee, tea and some
types of soft drinks and also can cause dehydration so
limit drinking and much better if water nalang ang iniinom
and as for his diet the patient should have small frequent
low fat meals like these veggies, fruits, whole grains,
beans and lentils and also lean means that can help the
patient his acute pancreatitis meet their protein needs.

These foods are recommended for people with pancreatitis

because they tend to be naturally low in fat, which eases
the amount of work the pancreas needs to do to aid
digestion. Kasi this is better for the pancreas it can
minimize the extra workload of the pancreas meaning fast
foods and fried foods and high processed such as burgers
and french fries, can be problematic for the patient in his
acute pancreatitis.

The pancreas helps with fat digestion, so foods with more

fat make the pancreas work harder and also high fats food
to avoid, dairy products, chips, mayonnaise, processed
meats such as hotdogs and etc., are needed to be avoided
pancreas to heal after that follow up assessment will be
made.

21. Write an ADIME note that provides your initial

nutrition assessment and enteral feeding
recommendations.

NUTRITION ASSESSMENT

(For his food/nutrition related history of the patient it is

based on his history of patient illness, alcohol use,
scheduled medications, and nutrition)

FOOD/NUTRITION RELATED HISTORY

● Eats out a little in 3 days. Usually eats out for dinner;
coffee and bagel toast in the morning; and lunch
usually a sub sandwich or pizza
● He no longer exercising due to busy schedule in
graduate school
 ● Alcohol use: 6 pack beer, 4–5 “shots” bourbon daily;
weekends: beer, bourbon, wine, and other mixed
drinks
● He was trying to stop his anti-depressant
medications since he’s alcohol intake increases.
● Eaten very little over the past 3 days because of
pain, nausea, and vomiting.
● Fluid Requirement: 1900 - 2400 mL
● Scheduled Medications: Imipenem, Famotidine,
Meperidine, Ondansetron, Docusate sodium,
Magnesium hydroxide and Lorazepam.

ANTHROPOMETRICS
● Weight - 245 lbs
● Weight change - increased 50 lbs over the last 5
years
● Height - 5’11
● BMI - 34.13 - Obese Type 2 (WHO, Asia Pacific)
● DBW - 72 kg
● UBW - 195 lbs.
● %UBW - 125.6%

BIOCHEMICAL DATA, MEDICAL TEST, AND

PROCEDURES
(HERE ARE THE LABORATORY VALUES OF THE PATIENTS
THAT ARE DEVIATED FROM THE NORMAL VALUES)

BUN ELEVATED

CREATININE SERUM ELEVATED

GLUCOSE ELEVATED

BILIRUBIN ELEVATED
TOTAL/DIRECT

ALBUMIN LOW

ALKALINE PHOSPHATASE ELEVATED

ALT ELEVATED

AST ELEVATED

CPK ELEVATED

LACTATE ELEVATED
DEHYDROGENASE

LIPASE ELEVATED

AMYLASE ELEVATED

CRP ELEVATED

CHOLESTEROL ELEVATED

LDL ELEVATED
 TRIGLYCERIDES ELEVATED

WBC ELEVATED

NEUTROPHIL ELEVATED

SEGS ELEVATED

BANDS ELEVATED

PROTEIN ELEVATED

KETONES ELEVATED

BILIBURIN ELEVATED

URIBILINOGEN ELEVATED

PROT CHK ELEVATED

NUTRITION FOCUSED PHYSICAL FINDINGS

(It was noted in his nursing assessment that his
general appeance is… paki state nalang po)

 General Appearance: Pale, obese male in obvious

distress
 Abdominal: Hypoactive bowel sounds, abdominal
tenderness, rebound, guarding, nausea, and
vomiting

CLIENT HISTORY
(For the client history of the patient, it will be based on
his personal, medical, family, and history)

● 29 years old, Male

● Single
● Filipino
● Roman Catholic
● PhD student in computer science; in school full-time;
works as research assistant in department
● Lives with roommate
● Patient has medical diagnosis of depression
● Undergone surgery of appendectomy at age 12
● Patient has maternal history of breast cancer and
paternal history of hypertension

NUTRITION DIAGNOSIS

 Excessive alcohol intake related to depression, as

evidenced by patient history of drinking 6 pack beer,
4–5 “shots” bourbon daily; weekends: beer, bourbon,
wine, and other mixed drinks
 Obesity (Obese ​ Type II), related to busy schedule as
evidenced by lack of physical activity and gradual
unintentional weight gain
 Undesirable food choices, related to busy schedule as
evidenced by patient history of usually eating out (fast
foods)

The nutrition diagnosis of the patient are based on the

PES statement by diagnosing him of excessive alcohol
intake, patient is Obese and lastly his undesirable food
choices these are evidenced by depression and also in his
patient history, lack of physical activity and gradual
unintentional weight gain and usually eating out fast
foods intake because of busy schedule

NUTRITION INTERVENTION

1. It is recommended Peptamen at 100 mL/hr. That will

start at 20mL/hr, titrate by 10-20 mL/hr every 4 hours to
goal. This will provide 2520 kcal, and 126 grams of
protein.

* Yung infusion rate nya nag start by 20mL/hr tas yung

tuloy or patak ng formula na pumapasok sa tubo dapat
10-20ml/hr and dahil ang goal rate neto ay 100mL/hr to
be able to achieve that goal yung daloy nung Peptamen sa
katawan ni patient ay kailangan controlled parin para
hindi ma overfeed or underfeed thats why it will provide
the 2520 kcal, and 126 grams of protein of the patient
2. Establish a weight goal the patient can accept that
range to 67-77 kg

* Para ma establish yung weight goal kailangan bigyan ng

nutrition counseling ang patient by speaking with the
patient respectfully and working with them so that it can
play a key role in helping them improve their health and
also dahil may weight goal ang patient which are the
upper and lower limit na nag rrange ng 67-77 kg and also
to determine whether the patient is willing to acknowledge
that he should make lifestyle changes that might improve
their health and how ready they may be to begin actually
making those changes.

3. Encourage the patient to strictly avoid drinking alcohol

and follow low fat diet. Increase water and fluid intake
that will be 2400 mL or 8-10 glasses per day.

* Based on the patient history and diagnosis, he should be

abstaining drinking alcohol and should be encourage by
counseling the patient that is because it can cause more
damage in his pancreas if i cocontinue niya pa ito and
should be following his low fat diet that can help him in
recovering from pancreatitis. Since need din iincrease ang
water and fluid intake that is because of his excessive
intake of alcohol and dehydrated ang patient so thats why
need sya increase so that he can function well and also it
is particulary important for his health. Making sure that
the patient is getting enough water each day. It’s one of
the best things that patient can do for his overall health.

4. Check the laboratory values and input/output intake of

the patient.

* By checking the laboratory values and input/output

intake of the patient it ensure that the patient has proper
intake of fluid and other nutrients. It has a function and a
responsibility in this laboratory's values to provide
clinicians with accurate information to help them interpret
the findings correctly.

NUTRITION MONITORING AND EVALUATION

1. Monitor Mr. JM’s tolerance to enteral nutrition support

of the patient. Also to reassess the EN formula of the
patient may take place based on changes and to make
sure they are accurate for the patient’s needs.

* Kailangan i monitor yung EN niya para nga po ma

prevent yung underfeed or overfeed depending on patient
situation and also to see if he can tolerate the goal rate ng
Peptamen at 100mL/hr na dumadaloy sa katawan niya
para ma prevent yung unprecedented issues na pwede
mangyari like vomiting, so that masigurado yung
binibigay na needs ng patient. Also it must be monitored
to assess the effectiveness of the nutrition support of the
patient and malaman if nag ffunction ba ng maayos ang
pancreas ng patient

2. Weight will need to be reassessed. Monitor his weight

every week to see if he's making any progress, and at the
end of the week, see whether he's progressively getting
closer to his goal weight.

* Since obese nga po yung patient, need po natin i

monitor ang kanyang weight if there are some changes or
naachieve niya naba yung desired body weight niya. So
monitor po ang weight niya weekly and continue to assess
diet and physical activity.

3. Provide a food diary to the patient that he will use to

write all of his food and fluid intakes. Check the 3-day
food recall with fluid intake upon the next scheduled
check-up to evaluate his food intake if he achieved and
followed his diet.

* Need i check ang food recall through his food diary niya
para malaman if nalilimit or naabstain niya na ang pag
inom ng alcohol at kung sinusunod niya ba yung diet and
if they are improvements sa eating habits of the patient
and also if he is increasing his fluid intake to 8-10 glasses
per day.

4. Monitor the input or output of the patient and include

the electrolytes, nitrogen balance, glucose, and other lab
values (Lipase, Amylase, and CRP)

* Monitor if there some improvements or deterioration sa

mga laboratory values such as lipase, amylase, and crp,
and yung mga input and output intake ng patients
including the electrolytes, nitrogen balance, and glucose
na kailangan i monitor. It is only in situations where there
is clear indication that the patient’s intake needs to be
monitored and controlled that an I-O chart is indicated.