Case Study 2: Tube Feeding Case Study - Weebly



Case Study 2: Tube Feeding Case Study

JB is a 30 year-old white male who works as a roofer for a building contractor. He fell from a third floor roof, suffering from multiple fractures and a severe head injury. He was chemically sedated using Diprovan at 7ml/hr. Unable to take foods orally, a nasogastric tube was inserted for feeding. Full strength Jevity 1.2 at 15 ml/hour was ordered initially, and then advanced 10 ml every 8 hours to the rate of 40 ml/hr which was prescribed by the physician. JB had mild diarrhea when the tube feeding was first initiated, but this resolved after 2 days. At the time of admission, JB was 6’ tall and weighed 185 lbs, his usual body weight.

[pic]Two weeks later, JB, has been weaned off of sedation and is transferred to the Neurology unit. By this time he weighed 152 lbs. A PEG tube was inserted one day prior to his transfer to the Neurology unit.

One week later (three weeks after initial injury), the speech therapist determines JB is regaining his ability to swallow. She recommends that JB is placed on a NDD 1-pureed diet. JB’s social worker is trying to transfer him to a rehabilitation facility (rehab). In order to be accepted at this facility, JB must be able to participate in therapies to relearn activities daily living (ADL’s).

Objective Data

Gender: Male

Age: 30 years

Height: 6’

Weight. (admit): 185 lb.

Weight. (transfer) 152 lb.

|LABS |Admission |Transfer |Normal |

|Hct |45% |39% |39-49% |

|Hgb |15 g/dL |13.2 g/dL |14-18 g/dL |

|Alb |4.8 g/dL |3.6 g/dL |4.0-6.0 g/dL |

|Na |142 mEq/L |144 mEq/L |135-145 mEq/L |

|K |3.7 mEq/L |4.0 mEq/L |3.7-5.2 mEq/L |

| | | | |

|Prealbumin |20 mg/dl |12 mg/dl |18-35 mg/dl |

Name_Kelsey Starck____________ Section_001______

Type your answers for the following questions. Please submit this case study online through Blackboard and bring a paper copy to class. Ensure that all pages of the paper of fastened together with a staple or binder clip.

1. Why was JB placed on a tube feeding and not total parenteral nutrition when he was admitted to the hospital?

JB was placed on tube feeding instead of TPN because JB’s gastrointestinal tract was capable of digesting and absorbing the nutrients. According to his case study there is no evidence of injury to his GI tract, therefore it is important to stimulate the gut via tube feeding to preserve GI and immunity function.

2. JB initially had some diarrhea. Why did this occur?

Diarrhea is common with tube feedings for various reasons. It is likely that JB is on antibiotics, has bacterial overgrowth in the colon or slowed GI motility due to his traumatic accident. Often tube fed patients react differently to the different osmolality’s of the tube feeding products. JB also could have been adjusting to the osmolality of the Jevity 1.2 before his diarrhea stopped.

3. What complications would you watch for while JB is on a nasogastric feeding?

Unfortunately, there are many complications that can occur with nasogastric feedings. The most prevalent complications are, nasal irritation, incorrect position of the tube leading to respiratory damage, mucosal damage at insertion site, and vocal cord paralysis.

4. Does the tube feeding rate written by the physician meets JB”s calorie and protein needs? If not, what should his goal rate be?

The feeding rate written by the physician of Jevity 1.2, 40 ml/hr does not meet JB’s caloric and protein needs according to the following calculations;

-HBE: 66 + (13.7 + W) + (5 X H) – (6.8 X A)

=66 + (13.7 X 84.1 kg) + (5 X 182.9 cm) – (6.8 X 30yrs)

=1,928.7 kcal/day X 1.4 (trauma IF) = 2700 kcal/day

-Diprovan Calculation: (1.1 kcal/ml X 7ml X 24hrs) = 184.8 kcal/day

-Total calorie requirement= (2700 kcal/day – 184.8 kcal/day) = 2515 kcal/day

-Protein needs 1.5 – 2 g/kg trauma

=(1.5 g/kg X 84.1kg) = 126 g/day

-Total Volume Tube Feeding per 24hrs Jevity 1.2 = (2515 kcal/day / 1.2 kcal/ml) = 2095ml/day

-Total Volume per hour = (2095 ml/day / 24hrs) = 87.3 ml/hr = 90 ml/hr

-Protein (g/L) Jevity 1.2 = (2.095L/day X 55.5g/L) = 116.3 g/day + one additional prosource per day = (15g/day +116.3 g/day) = 131 g/day

The calculations shown above prove that JB must receive at least 90ml/hr of Jevity 1.2 to meet his requirements

5. Calculate ideal body weight (IBW) for JB. Calculate his %IBW at admission and when he was transferred to the neurology unit. Calculate his %UBW at transfer. According to the assessment handout chart, how would you assess his nutrition status on admit and transfer?

-IBW = 106lbs + (6 X12in) = 178lbs

-%IBW admission= 185/ 178 X 100 = 103%

-%IBW transfer = 152 / 178 X100 = 85%

-%UBWtransfer= 152/ 185 X100 = 83% moderately underweight

According to the assessment handout chart, JB was at an adequate weight (103% ideal body weight) upon admission to the hospital. When JB transferred to the neurology unit, he had dropped to 83% of usual body weight and became moderately underweight. This drastic weight loss in only two weeks is very concerning. JB isn’t meeting his nutritional needs.

6. At admission, were there any concerns regarding JB's nutritional status based on his body weight and labs? At the time of transfer to the neurology unit? (in other words, what is your assessment of his nutritional status).

Upon admission all of JB’s lab values fell within normal standards. His prealbumin lab value and the fact that he was 103% of his IBW indicated that he was acquiring adequate nutrition. JB’s time spent in the ICU showed a drop in all of his normal lab values and a large drop in his weight in just two weeks. JB’s nutritional demands were not met while he was in intensive care. Although he suffered from a head injury, the physician and RD should have adjusted JB’s caloric needs. Furthermore, upon transfer JB’s prealbumin lab value of 12 mg/dL is an indication that he was severely malnourished in the ICU because his prealbumin labs dropped so quickly. At JB’s time on transfer to the neurology unit he is malnourished and continues to lose weight.

7. Calculate JB's caloric needs at admission and upon transfer. (Use kcal/kg and a predictive equation).

-Caloric needs upon admission - HBE: 66 + (13.7 + W) + (5 X H) – (6.8 X A)

=66 + (13.7 X 84.1 kg) + (5 X 182.9 cm) – (6.8 X 30yrs)

=1,928.7 kcal/day X 1.4 (trauma IF) = 2700 kcal/day

Kcal/kg = (2700 kcal/day / 84.1kg) = 32 kcal/kg

-Caloric needs upon transfer - HBE: 66 + (13.7 + W) + (5 X H) – (6.8 X A)

= 66 + (13.7 X 69.1 kg) + (5 X 182.88) – (6.8 x 30)

=66 + 966.7 +914.4 – 204

= 1723.1 kcal X 1.4 (trauma IF) = 2412 kcal/day

Kcal/kg = 2412 kcal/69.1 kg = 34.9 kcal/kg

8. Calculate JB's protein needs at admission and upon transfer. (Justify your numbers)

-Protein needs admission 1.5 – 2 g/kg trauma

=(1.5 g/kg X 84.1kg) = 126 g/day

-Protein needs transfer 1.5 – 2 g/kg trauma

= (1.5g/kg X 69.1kg) = 103.7 g/day

9. Calculate JB's fluid needs at admission and upon transfer. Are his fluid needs being met by the tube feeding? If not, what would you change? (both admission and transfer)

-Admission fluid needs = (1ml/kcal) = 2700 ml/day

-Transfer fluid needs = (1ml/kcal) = 2412 ml/day

-Jevity 1.2 Admission = (835ml/L X 2.160L/day) / 1000ml = 1.804 L provided by feeding

Water bolus = (2700 ml req. – 1804 ml provided) = 896 ml / 6times/day = 150ml bolus q 4°

-Jevity 1.2 Transfer = 1.804 L provided by feeding *kept same volume rate b/c JB should gain weight

Water bolus = (2412 ml req – 1804ml provided) = 608ml / 6times/day = 100ml bolus q 4°

10. Calculate the calories provided to JB from the medication Diprovan.

-Diprovan Calculation: (1.1 kcal/ml X 7ml X 24hrs) = 184.8 kcal/day

11. How many calories and grams of protein was JB receiving while on his tube feeding of Jevity 1.2 at 50 ml/hr, ? What would you recommend for a tube feeding product and rate once JB was transferred to the Neurology unit?

-Calories: 1.2kcal/ml X 50ml X 24hrs = 1440 kcal/day

-Protein: 55g/L X 1.2L/day = 66g protein/day

-Because JB is no longer having diarrhea, no longer on Diprovan and needs to gain weight, I would suggest he be on Jevity 1.5 kcal once he transfers to the neurology unit at 75 ml/hr.

Jevity 1.5 (2700kcal/day) / (1.5 kcal/ml)= 1800ml/day

(1800 ml/day) / 24hrs = 75 ml/hr

*utilized Jevity 1.2 at 50ml/hr instead of 40 ml/hr

12. Was the tube feeding recommendations adequate to meet JB's needs while in the intensive care unit?

See question #4

13. What is the reason for starting the tube feeding at a slow rate?

It was important to start JB’s tube feeding at a slow rate because it allowed the physician and registered dietitian to observe how JB tolerated the feedings. Starting at a slow rate will allow for JB to have complications on a smaller scale and slowly reintroduce the gut to feedings after a traumatic indecent. Often after trauma blood is shunted away from the GI tract and most likely to his head injury to allow him to heal. Slow introduction won’t overwhelm the system and avoid making JB sicker.

14. How will you change his tube feeding order to prepare him for transfer to rehab? Explain your answer.

When JB was transferred to the rehab facility he had begun to regain his ability to swallow, and was advised to begin the NDD 1-pureed diet. I think that it is important for JB to regain his ability to eat food normally, but it shouldn’t be done so quickly. It is likely that JB won’t be very interested in eating pureed foods to meet all of his nutritional needs; therefore, it may be beneficial to keep his nasogastric tube in place to supplement what he isn’t getting nutritionally with his pureed foods. The combination of the two would ensure that JB is getting enough energy and hopefully will gain some weight back.

15. Once JB has been at rehab for 3 days, he is eating poorly. What should the rehab dietitian do? Explain your answer.

After being in rehab for three days, JB isn’t eating enough nutrients to support his metabolic rate. It is crucial that the dietitian follows the above orders and supplements JB’s pureed meals with tube feeding via the nasogastric tube. JB cannot afford to lose any more weight so he must need his nutritional needs through a combination of tube feeding and the pureed diet. Furthermore, it is important to encourage JB to eat a pureed diet so that his transition to regular foods will go smoother.

16. Write one PES statement appropriate for the time of transfer to rehab.

Muscle and subcutaneous fat wasting (P.D. 1.1.1) related to inadequate nutritional needs via nasogastric tube as evidence by change of 103% to 83% IBW in two weeks in intensive care secondary to CHI.

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