Planning Nutrition Therapy for a Complex Pediatric Patient

 

Imagine that you are a nutrition assistant working at a pediatric rehabilitation center. This rehabilitation center
provides care for pediatric patients who are recovering from recent hospitalizations. This facility is considered
to be the bridge between critical care type hospitals and home care.
The supervising dietitian informed you that a new patient was admitted overnight from the nearby hospital and
is now recovering from a skin graft surgery due to a severe pressure ulcer (bed sore). Imagine that you are
asked to review the patient’s chart notes and provide a nutrition assessment summary along with
recommendations for a therapeutic diet or nutrition support (i.e. either enteral or parenteral nutrition with or
without an oral diet).
Patient information from the hospital medical chart:
Name: Cindy
Age: 6-year-old female
Height: 43 inches
Weight: 38 pounds
Admitting Diagnosis (Dx): Cerebral Palsy, bedridden, stage 3 pressure ulcer on sacrum, food allergy to eggs
Surgery: Skin graft performed to increase healing and reduce further infection risk.
Diet order: Thickened liquids and pureed foods with precautions due to dysphagia (swallowing deficiencies)
associated with CP. No eggs: Severe Egg Allergy.
Speech/Cognitive: Patient receives speech and swallowing therapy due to CP. Her speech and cognitive
abilities were reported to be around that of a 2-year-old.
Cindy normally resides at home with her family. She qualifies for state-funded home medical assistance due to
the CP diagnosis. She is bedridden and relies on the home health nursing assistants for care. Her parents
have three other children and involve her in as many family activities as possible, but the actual care is
provided by the in-home medical team. Cindy has had a gastrostomy feeding tube (G-tube) since she was just
a few months old. In recent years, it has only been used nocturnally if her oral intake of the pureed/soft diet
foods fell below the 50% mark for two or more meals. She received a specialized enteral formula that did not
have eggs as any source of the protein.
For many years, Cindy was cared for by the same team of nurses and nursing assistants, and she did not have
any major medical or nutrition-related problems. However, about 6 months ago, the state funded program
changed home care contract companies and a new company began to provide care. Cindy’s parents felt that
the care was sub-standard and reported it numerous times, but without any improvements. It was not until
Cindy’s quarterly check-up that these problems were identified. Her weight had dropped by 15% in just 3
months, her albumin was low, and her lean muscle mass and strength had decreased. Most alarmingly, she
had developed a pressure ulcer on the sacrum. The MD immediately admitted Cindy into the hospital.
Upon further investigation, the new home health company had been administering nocturnal tube feedings with
a formula that contained egg as one of the partial sources of protein. They thought that it was a comparable
substitute for the previous brand. Additionally, they had misread the original nutrition order to only give night
enteral feedings (via the G-tube) if her oral intake was insufficient. Until the issues were discovered, Cindy
went several months receiving a full night of tube feedings that provided a feeling of fullness to her. She also
was suffering from chronic diarrhea and associated malabsorption. Subsequently, she would not feel well
enough to eat the next day and the cycle repeated itself daily. She also started having many more nasal and
respiratory symptoms, which the new care providers explained away as being typical seasonal allergies. She
was prescribed an antihistamine. Her parents were unaware of the nocturnal tube feedings because the
nursing staff would run them about 8–10 hours while the patient was asleep.
Why was Cindy at risk for a pressure ulcer? What were some of the contributing factors, and why?
What are the symptoms of an egg allergy? Why do you think her allergy was not ever life threatening when she
was receiving the nightly tube feedings at home?
Take into consideration her multiple medical conditions of cerebral palsy, egg allergy, and recent pressure ulcer
surgery, and calculate her estimated calorie needs and protein needs.
Recommend an appropriate tube feeding formula brand name or type that has no albumin from egg protein (for
the days that she does not have adequate oral intake of her meals).
Appendix: Design a full-day meal plan for Cindy that includes pureed/soft foods. This diet needs to fully
address her CP-related chewing/swallowing challenges. Be sure to consider her protein needs for wound
healing promotion and future prevention, but without foods containing eggs or egg by-products. Oral protein
drink supplements can be considered. Include the total calories, carbohydrates, fats, protein, and any
micronutrients that are important in this case

 

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Studies on J. L. Mackie’s “Malicious and Omnipotence”

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william blake’s angelsThe contentions for and against God has won since the commencement of mankind. Scholars are enthusiastically prepared to banter about the subject of the presence of God, as this is one of the philosophical subjects of conversation that has stayed immortal, in that it has not gotten outdated. Those contending for the presence of God have not had the option to give enough proof to convince everybody who contended against the presence of God. The opposite is additionally valid. The doubters, regardless of the amount they attempted, or how much “rationale” and “logical perceptions” they utilized, have not had the option to convince the adherents of God in their cases. J. L. Mackie, in his paper Evil and Omnipotence, attempts to demonstrate that having faith in a compelling and all great god is nonsensical. His essential purpose of center is the presence of wickedness, which, he asserts, conflicts with the presence of an all decent god. He considers some normal contentions for an all decent god and shreds them down, indicating that consistently, such a divine being can’t exist. Has his legitimate “proof” convinced devotees to never again put stock in God? I would think not, and the explanation I state this is on the grounds that J. L. Mackie had neglected to consider and censure a view that dispenses with the one thought whereupon he based his whole contention. We will investigate this view right now, first, let us quickly take a gander at the fundamental establishment for Mackie’s contentions.

J. L. Mackie utilizes the issue of malice to show that faith in an all decent god is unreasonable. Mackie contends that on the off chance that a supreme and ethically flawless god exists, why at that point is there such a great amount of abhorrence right now? He clarifies that the presence of insidiousness is an immediate inconsistency of God being all acceptable. Mackie, at that point, investigates some basic theist reactions to these inquiries and endeavors to demonstrate them unreasonable. He expresses that in the event that one acknowledges that insidious exists, at that point the individual in question can’t acknowledge that God is both all-powerful and ethically great. Mackie says that an answer for this issue of underhandedness is to either accept that God isn’t all-powerful, God isn’t totally acceptable, or accept that detestable is just a figment. And still, at the end of the day, Mackie proceeds, there emerge strict inconsistencies while dismissing one of the three thoughts. One might say, Mackie is stating that religion is unreasonable.

For the individuals who despite everything maintain the three thoughts, Mackie shows that the thinking behind their convictions is imperfect in that it by implication shows that one of the three features are bogus. A few models are as per the following. Adherents contend that, “Detestable is essential as a way to great.” Mackie contends that if God is supreme, would he be able to make great without making underhanded; is it not this protection obliging God’s capacity by his own law? Another protection that adherents make for God is that, “Acceptable can’t exist without shrewdness” or “Fiendishness is important as a partner to great.” Mackie contends that something doesn’t really require a partner. He gives a model that while it may appear as though we need different hues for the shading red to exist, it isn’t really valid. Everything known to mankind could have been red. Obviously, we would not see red, he clarifies, nor would we have a name for that shading. By the by, red would at present exist. He investigates different resistances by the devotees and scrutinizes them, including the guard that says that malicious is an instrument to enhance a more significant level of good. In any case, Mackie contends that the presence of a more significant level of good implies that there is a more elevated level malice. Mackie calls these barriers “fraudulent arrangements.” However, these arrangements that he reprimanded are themselves constrained, and in this manner, had the option to be demonstrated silly by Mackie. In any case, the accompanying arrangement that we will investigate totally settle the issue of underhandedness without expecting to forfeit the faith in any of the three thoughts.

The arrangements that Mackie assaulted just centered around one side of the condition, in particular, these arrangements attempted to clarify the issue of shrewdness by taking a gander at common life as opposed to likewise thinking about existence in the wake of death. Presently, since most theists put stock in an in the future, it is sheltered to utilize the presence of the great beyond as a contention to counter the issue of fiendishness. As per most theist convictions, the kind of life we lead right now decide our status in an everlasting life after our demise. Specifically, the individuals who perform all the more great deeds right now go to a forever cheerful heaven, or paradise while the individuals who went through their natural time on earth doing shrewdness would endure discipline (endless or not, contingent upon their activities right now) existence in the wake of death. This view obviously shows that positive attitude prevail upon underhanded. In any case, this view additionally achieves different inquiries that ought to be talked about.

One may inquire as to why God has placed us on Earth in any case. On the off chance that God was all acceptable and all amazing, wouldn’t he be able to have taken us directly to paradise before we even gotten an opportunity to do detestable? I think posing an inquiry like this is fascinating, yet pointless. This is equivalent to inquiring as to why gravity exists, or for what reason are molecules just made out of protons, neutrons, or electrons, or for what reason did the enormous detonation occur. Indeed, even science can’t address these inquiries. Science addresses the subject of “how,” not “why.” Science answers “how gravity works,” not “why gravity works.” Science answers “how creatures advanced” not “why developmental hypothesis exists.” Science may discover clear subtleties on the theory of prehistoric cosmic detonation and how it occurred, however I question it will ever have the option to answer why it occurred. Along these lines, inquiring as to why we are on Earth is as trivial. Had we been in paradise constantly, would not we at that point inquire as to why we are on paradise and not Earth?

Most supporters of Abrahamic religions accept our life on Earth is a test for ourselves. The conviction is that every single one is given an interesting test and that every individual must experience it so they may learn humankind. The individuals who prevail by having trust, investing great exertion, and attempting to accomplish others conscious objectives will be remunerated in life following death and likely right now well. The individuals who fall flat and resort to detestable by losing any desire for progress will be rebuffed in the great beyond and perhaps right now. This is seen by us all right now, or not we have confidence in God. For instance, an individual who decides to place in difficult work and forfeits some enjoyment during school life, their arrival at last will be a lot more noteworthy. He will have the option to have an establishment for their life and bliss will probably come. Somebody who overlooks their investigations and has a lot outside enjoyment during school years, their final product will be very different. More probable, the last individual will lead a less upbeat and pleasant life than the previous over the long haul. Does it bode well, at that point, to call school detestable on the grounds that it makes an individual battle and buckle down? It can’t be insidious in light of the fact that its objective is for giving gigantic advantages later on. Similar remains constant for the battles on Earth, as its point is for improving as an individual and getting unceasing joy.

Enduring is a piece of the test, and the individuals who have expectation and battle for joy, God guarantees them satisfaction. This is even valid for the individuals who are casualties of abhorrence. For example, a youngster, whose guardians have been killed, is given a specific test by God. The individual in question needs to beat certain battles of adapting to such a misfortune to improve as an individual. Instances of the best individuals in history show that they needed to experience incredible battles in their initial lives. Since they had the option to adapt to these problems, they were effective and upbeat. Here is another model: the absolute best supporters of research for remedies for a specific illnesses had endured those maladies themselves. Battle isn’t an abhorrence, however it is somewhat a test for an individual—and that individual is guaranteed endless bliss and achievement in the event that the person in question breezes through the assessment.

Some vibe that demise is malevolent. Notwithstanding, we as a whole pass on, and on the off chance that we have confidence in an endless in the future, demise can’t be malicious. Truly, some beyond words than others, yet think about that as somebody taking a shorter test. One who carries on with a more extended life has a greater test to take and has more desires from God. The individuals who are casualties of homicide, note that the people in question (in the event that they are acceptable themselves) will carry on with a cheerful next life while the killer will be rebuffed. Where is the insidiousness in that?

Mackie gives a convincing contention indicating that confidence in an impeccably good, all compelling god is silly. He put together his contentions with respect to the issue of abhorrence; nonetheless, he didn’t think about the perspective on malevolent as a test. This view tackles the issue of abhorrence by demonstrating that there is a the hereafter. When taking a gander at this life and the following coexistence, we see that abhorrent does come up short, and God is, in fact, a splendidly good being.

Composed by Nazmus Shakib Khandaker with alters.

basic paper, article about existence, religi

 

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