Case Study 2: Tube Feeding Case Study - Olivia Misa



Leana Scherer

Case Study #2

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

JB was put on tube feeding instead of TPN because his gut is still fully functional. The gut must be used whenever possible in order to maintain morphological as well as functional characteristics. The cells of the gut will undergo apoptosis when they are not used.

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

JB initially had some diarrhea because his GI system was adjusting to a full liquid diet as opposed to the bulky foods he was used to consuming.

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

Potential complications on the nasogastric feeding is nasal necrosis, sinusitis, dislodged tube,

4. 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.

ADMISSION: Actual-167 lbs, IBW- 154 lbs, %IBW- 108%

TRANSFER: Actual- 159 lbs, IBW- 154 lbs, %IBW- 103%

5. 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).

Initially at admission there were no concerns with JB’s nutritional status. His lab values were all within normal ranges and his weight was not far off from his IBW. At time of transfer JB had lost some weight but was still within a normal weight range. However, at time of transfer JB’s lab values look concerning—his Hgb, Albumin, and Prealbumin are all low indicating that he is protein-energy malnourished.

6. Calculate JB's caloric needs at admission and upon transfer to the neurology unit. (Use kcal/kg and a predictive equation).

ADMISSION: weight-76 kg, height-173 cm

Kcal/g formula: 25-28 kcal/kg X 76 kg = 1900 kcal-2128 kcal

Mifflin St. Jeor: RMR= 1624 kcals X 1.3- 1.5 (trauma stress factor) =

2111 kcal- 2436 kcal

Caloric needs at admission: About 2130 kcals/day

TRANSFER: weight-72 kg, height- 173 cm

Kcal/g formula: 25-28 kcal/g X 72 kg = 1800 kcal- 2016 kcals/day

Mifflin St. Jeor: RMR= 1584 kcals X 1.3- 1.5 (trauma stress factor) =

2059 kcals- 2370 kcals

Caloric needs at transfer: 2100 kcals/day

7. Calculate JB's protein needs at admission and upon transfer to the neurology unit (Justify your numbers)

ADMISSION:

1.2- 2 g/kg = 91 to 152 g Protein; recommendation: 100 g Protein/day. I chose a number on the lower end of the range since initially his protein levels in the blood were good.

TRANSFER:

1.2- 2 g/kg = 86- 144 g Protein; recommendation: 115 g Protein/day. I chose a number in mid range due to JB’s low protein levels in the blood at time of transfer.

8. 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:

Needs- 1 mL/kcal X 2130 kcals = 2130 mL/day

TRANSFER:

Needs- 1 mL/kcal X 2100 kcals = 2100 mL/day

JB was receiving 968 mL of fluid from his tube feed regimen which is very inadequate for both admission fluid needs and transfer fluid needs. I would recommend add ing water flushes in between feedings.

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

5 mL Diprovan/ I hour X 1.1kcal/1 mL Diprovan X 24 hour/ 1 day = 132 kcal/day

10. How many calories and grams of protein was JB receiving while on his tube feeding of Jevity 1.2 at 50 ml/hr, ? Were the tube feeding recommendations adequate to meet JB's needs while in the intensive care unit? If not, what would you recommend for a tube feeding rate and product once JB was transferred to the Neurology unit?

1.2 kcal/1mL X 50 mL/1 hour X 24 hour/day = 1440 kcals from Jevity1.2 + 132 kcals Diprovan = 1572 kcals

55.5 g Protein/1 mL Jevity 1.2 X 50 mL/1 hour X 1 L/1000mL X 24 hour/1 day = 66.6 g Protein/day

Neither caloric needs nor protein needs were met while JB was on 50 mL of Jevity 1.2. I would change the tube feed as follows:

Jevity 1.5 60 mL/hour for 24 hours with 1 pack beneprotein in 100 mL H20 every 6 hours and 150 mL H20 flushes every 6 hours.

This provides 2260 kcals/day (2160 kcals from Jevity 1.5, 100 kcals from beneprotein); 116 g Protein (91.8 g from Jevity 1.5, 24 g from beneprotein); 2114 mL of fluid (1094 mL from Jevity 1.5, 400 mL from modulars, and 620 mL from free water flushes).

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

The reason for starting the tube feeding at a slow rate is to avoid refeeding syndrome. In refeeding syndrome patients have typically be malnourished prior to start of tube feed and when the feeding starts they can experience fluid and electrolyte disorders and it can be fatal.

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

JB should very slowly be weaned off of his tube feed and initially on a clear liquid diet only. JB can start with a continuous drip at night of Jevity 1.5- 55 mL for 1 hour, 110 mL for 12 hours, 55 mL for 1 hour with a pack of beneprotein mixed with 100 mL of water every 3 hours. During the day he can have clear liquids such as broth, water, juice. As tolerated, JB can switch to full liquid diet and drink his formulas instead of receive them via tube feed.

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

The rehab dietician should question why he is eating poorly. She should question if it is food preference, trouble chewing or swallowing, GI upset. If he has moved on to a full liquid diet and is not tolerating it she should move him back to a clear liquid diet. If this does not work she should consider whether he needs to be readmitted and go back on a tube feed diet.

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

Inadequate oral intake (NI-2.1) r/t limited acceptance of oral foods AEB nurses report JB is not eating much.

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