I.

INTRODUCTION

a. Clinical Impression

➢ Pulmonary Tuberculosis (Stage 4)

Pulmonary Tuberculosis is a potentially serious infectious disease that mainly
affects your lungs. It is caused by the bacterium Mycobacterium tuberculosis (M
tuberculosis). These bacteria of tuberculosis are spread from one person to
another through tiny droplets released into the air via coughs and sneezes. It is a
contagious bacterial infection that involves the lungs. It may spread to other
organs.
Certain signs of PTB are quite typical:
● Prolonged cough (lasting more than 2 weeks) and sputum production,
while others are less so: weight loss, anorexia, fatigue, shortness of breath,
chest pain, moderate fever, and night sweats.
● Haemoptysis (blood in sputum) is a characteristic sign present in about
one-third of patients.
Advanced forms and complications are not uncommon. These include:
● Respiratory insufficiency due to extensive lesions and destroyed lungs;
● Massive hemoptysis due to large cavities with hypervascularization and
erosion of vessels;
● Pneumothorax due to the rupture of a cavity in the pleural space.
In an endemic area, the diagnosis of PTB is to be considered, in practice, for all
patients who have experienced respiratory symptoms for more than 2 weeks.

➢ Bronchitis
Bronchitis is characterized by inflammation of the bronchial tubes (bronchi), the
air passages that extend from the trachea into the small airways and alveoli.
Chronic bronchitis may result from a series of attacks of acute bronchitis, or it
may evolve gradually because of heavy smoking or inhalation of air contaminated
with other pollutants in the environment. When so-called smoker's cough is
continual rather than occasional, the mucus-producing layer of the bronchial
lining has probably thickened, narrowing the airways to the point where breathing
becomes increasingly difficult. With immobilization of the cilia that sweep the air
clean of foreign irritants, the bronchial passages become more vulnerable to
further infection and the spread of tissue damage.
Symptoms of bronchitis include the following:
● Cough ● Dyspnea
● Sputum production (clear, ● Sore throat
yellow, green, or even ● Runny or stuffy nose
blood-tinged) ● Headache
● Fever ● Muscle aches
● Nausea & vomiting ● Extreme fatigue

➢ Asthma
The 2007 Expert Panel Report 3 (EPR-3) of the National Asthma
Education and Prevention Program (NAEPP) noted several key changes in
the understanding of the pathophysiology of asthma :

1. The critical role of inflammation has been further substantiated,

but the evidence is emerging for considerable variability in the
pattern of inflammation, thus indicating phenotypic differences
that may influence treatment responses
2. Of the environmental factors, allergic reactions remain important.
Evidence also suggests a key and expanding role for viral
respiratory infections in these processes
3. The onset of asthma for most patients begins early in life, with the
pattern of disease persistence determined by early, recognizable
 risk factors including atopic disease, recurrent wheezing, and
parental history of asthma
4. Current asthma treatment with anti-inflammatory therapy does not
appear to prevent progression of the underlying disease severity

The pathophysiology of asthma is complex and involves the following

components:
- Airway inflammation
- Intermittent airflow obstruction
- Bronchial hyperresponsiveness

➢ Anemia
Anemia is defined as an absolute reduction in the quantity of the
oxygen-carrying pigment hemoglobin (Hgb) in the circulating blood.
Anemia is further broadly subcategorized into acute and chronic.
Anemia usually is grouped into 3 etiologic categories: decreased red blood
cell (RBC) production, increased RBC destruction, and blood loss.
Common conditions associated with anemia include the following:

- Gastritis
- Gastric or duodenal ulcer
- Liver or renal disease
- Hypothyroidism
- Sickle cell disease
- Hypermenorrhea
- Previous history of anemia or blood transfusions
- Thrombocytopenia or blood coagulation disorders
- Cancer or other chronic illness (eg, rheumatic disease)
- Poor diet, especially iron deficiency
b. Nutrition Drug interaction

Table 1: Patient Kramer’s list of medications

Medication Dosage Nutrient Interaction

Pulmonary Tuberculosis Rifampin Depletes and Interfere

interaction of:
Isoniazid - Folic Acid
Pyrazinamide - Potassium
- Vitamin B12
Ethambutol - Vitamin B2
- Vitamin B3
Streptomycin (Niacin)
- Vitamin B6
- Vitamin K
- Calcium
- Magnesium
- Vitamin D
- Vitamin E

Bronchitis Analgesics Analgesics are drugs that

relieve pain and often
cause stomach irritation.
A full stomach lowers
the risk for stomach
irritation

Antibiotics - Vitamin K

Ventolin - Calcium
- Magnesium
- Phosphate
Asthma - Potassium

Anemia Iron supplements Iron might decrease how

much antibiotic the body
absorbs. Might decrease
the effectiveness of
some antibiotics
 II. NUTRITION CARE PROCESS/ PLAN
➢ Patient H.K. weighs 47 kilograms and stands 5’5” tall he has a body mass index
of 17.2 kg/ m2 which is classified as underweight by the World Health
Organization (WHO). His usual body weight is 49 kilograms. While her Ideal
Body Weight should be 59 kilograms. Upon admission his chief complaint is
difficulty in breathing also he has been diagnosed with Pulmonary tuberculosis,
Bronchitis and Asthma. He brought his biochemical result that was taken last
September ​(shown in Table 2)​.
See Attachment of NRS 2012 & SGA (Table 2 and 3)

1. Nutrition Screening & Assessment

a. Biochemical Assessment

Table 5 shows the pertinent laboratory finding of patient HK and the possible indications with the variability of each
parameter from the normal references.

Biochemical Parameters Findings Normal values Indications

Hemoglobin 70 140 - 170 g/L Low; ​Blood loss or

Anemia

Hematocrit 0.17 0.42 - 0.50 g/L Low; ​Can cause

heart failure

RBC 6.5 4.5 - 5.9 Elevated;

WBC 11.1 4.0 - 10.5 Elevated;

Lymphocyte 0.24 0.24 - 0.44 Normal;

Neutrophil 0.56 0.36 - 0.66 Normal;

Monocyte 0.11 0.02 - 0.12 Normal

Platelet count 155 150 - 450 Normal;

Platelet count 190 150 - 450 Normal;

Albumin 1.5 3.5 - 5.5 g/dL Low;

Sodium 143 142 mEq/L Elevated;

 b. Clinical Assessment
The chief complaint of the patient was difficulty in breathing and fatigue.
It was included in his medical history that he has Pulmonary tuberculosis
stage 4; Secondary Bronchitis; Asthma; Anemia.

c. Dietary Assessment
Patient H. K. is diagnosed with Pulmonary Tuberculosis Stage 4 which
causes alteration of metabolism. H. K. also has a poor appetite which
causes him to have inadequate food intake.

d. Lifestyle
Patient H. K. was said to be a heavy drinker and a heavy smoker in the
past which is also a risk factor for his current status.

2. Diagnosis

➢ Underweight related to inadequate food intake associated with heavy

drinking and smoking as evidenced by BMI of 17
➢ Inadequate oral intake ​related to d​ ecreased appetite ​as evidenced by ​4.1%
weight loss.
➢ Increased protein and iron needs ​related to P ​ ulmonary infection ​as
evidenced by l​ ow hemoglobin laboratory values.

e. Intervention
Table 6: ​Diet Prescription of Patient H. K. Short and Long Term
Short Term Goal:

Diet Rx: 2400 KCAL, C 353, P 71g, F 67g; 3 meals, 3 snacks

Recommendation Rationale

Kcal- 2,400
- IBW: 59 x 40 = 2,360 or 2,400 kcal Small frequent feedings for adequate
CHO- 353g Using NPC distribution: intake of nutrient-dense food
- 1.3 grams protein/kgIBW
CHON- 71g Feed or serve the main meal when the
- 76.7 or 77g Protein
energy level is high and the patient is
FAT- 67g 77 x 4 = 308 kcal
active
2,400 kcal - 308 kcal = 2,092 kcal
70% - 30% distribution
- C:2,092 x.70 = 1464/ 4 = 366g
- F: 2,092 x.30 = 628/ 9 = 70g
Long Term Goal:
Diet Rx: 2400 Kcal; C 360g, P 90g, F 67g; 3 meals, 3 snacks
Recommendation Rationale

Kcal- 2,400 - IBW: 59 x 40 = 2,360 or 2,400 kcal
60% CHO, 15% CHON, 25% FAT
CHO- 360g
- C: 2,400 x 60% = 1,440/4 = 360g
CHON- 90g - P: 2,400 x 15% =360/4 = 90g
- F: 2,400 x 25% = 600/9 = 67g
FAT- 67g
- To increase and achieve ideal
body weight
- Nutrient-dense food must be
given
- Small frequent feedings
- Give patient the main meal when
active and high energy level

Table 7: ​Distribution of Exchanges

List of # of Ex Energy Carbohydrates Protein Fat BF AM L PM D BT

Food

Veg A 4 48 9 3 - 1 1 1 1

Fruits 5 200 40 - - 1 1 1 1 1

Milk 12 456 62.4 16.8 15.6 1 1

(Ensure) scoops

Sugar 6 120 30 - - 1 1 2 1 1

Rice 9.5 950 218.5 19 2 1 2 2 1.5 1

M Low 3 123 - 24 3 1 1 1
E
A
Med 3 258 - 24 18 1 1 1
T

Fat 6.5 292.5 - - 32.5 2 1 1 1 1

Total: 2,447.5 kcal 359.9g 84.8g 69.1g

 Table 8: ​Sample menu

Menu Quantity & Ingredients

Breakfast ● Tofu-mushroom sisig - ½ cup tofu

- ¼ cup mushroom
- 1 tsp coconut oil
- 1 tsp sugar
- 1 egg
- 1 tsp calamansi juice
● Squash soup - 1 tbsp all purpose cream
- ¼ cup squash
● Rice - 1 cup
● Papaya - 1 slice

A.M. Snack ● Ensaymada - 1pc

- 1 slice cheese
● Orange - 1pc
● Ensure gold - 1 cup ensure

Lunch ● Fish steak Tagalog - 1 slice bangus

- 1 tsp calamansi juice
- 1 tsp oil
● Ginataang talbos ng gabi - ½ cup talbos ng gabi
- 1 tbsp gata
● Rice - 1 cup
● Mango - 1 slice

P. M. Snack ● Carrot Juice - 2 tbsp calamansi juice

● Mushroom Burger
- ¼ cup carrots
- 1 cup watermelon
- 2 tsp sugar
- ¼ cup assorted fresh mushroom
- ¼ cup bread crumbs
- 1 tbsp oats
- ¼ cup lean ground beef
- 1 burger bun

Dinner ● Rice - ¾ cup rice

● Chicken afritada - 1 pc chicken leg
- ¼ cup carrots
- ½ tbsp green peas
● Mango - 1 slice mango

Bedtime Snack ● Banana bread - 1slice

- ⅓ cottage cheese
● Ensure Gold - 1 cup
 f. Monitoring and Evaluation
Table 9: ​Monitoring and evaluation for patient
Evaluation

Monitoring Findings Goal Recommendation

1. Hemoglobin Anemia 136-172 g/L - Iron

supplementation

- Eat foods rich in

Vitamin C and Iron

2. Bodyweight Anorexia Achieve ideal body - Adequate oral

intake
weight of 59 kilograms

3. Peak flow Asthma Avoid asthma attacks - Refrain from going

monitoring to areas where you
can smell or inhale
smoke
4. Sputum culture Bronchitis Relieve symptoms, - Avoidance of
prevent complications environmental
X-ray
and slow the progression irritants, especially
of the disease cigarette smoke.

5. Visibility of Pulmonary Tuberculosis Reduction of symptoms - Completion of

symptoms treatment