ENTERAL NUTRITION CASE STUDY



ENTERAL NUTRITION CASE STUDY

A 23 yom is admitted to ICU s/p motorcycle accident. Dx with CHI, Glascow Coma Scale of 7. Has multiple fractures. Is on mechanical vent. No significant PMH. Pt is a weight lifter and plays football.

Ht. 6’3”, Wt. 230#

Labs: alb 2.5, glc 130, BUN 12, Cr. 0.8, Na 136, K 4.2

1. Determine the patient’s calorie, protein and fluid needs. Explain your answer (show your work).

20-25 cal/kg IBW: 20 x 89kg = 1,780

25 x 89 kg = 2,225

1,780-2,225 calories

-According to page 321 of Nutrition and Diagnosis-Related Care text, for patients that are ambulatory on a mechanical vent, you use 20-25 kcal/kg to assess their needs. Since there is not enough information to do Penn State Equation, I found this method to be most appropriate

1.2-1.5 g/kg IBW: 1.2 x 89 = 107 grams

1.5 x 89 = 134 grams

107-134 grams protein

-According to page 321 of the Nutrition and Diagnosis-Related Care text, 1.2-1.5 g/kg protein should be provided to patients on a mechanical vent

1 mL/kcal fluid: 1,780-2,225 mL fluid

-According to page 885 of the Nutrition and Diagnosis-Related Care text, it is important to avoid over hydration monitor fluid requirements and balance because a prolonged positive fluid balance may prolong the need for mechanical ventilation. To assess tube feeding flushes, you would be sure to look at how much fluid patient is receiving from IV fluids as well as free water in the tube feeding formula to avoid over hydration with excessive water bolus flushes.

2. List the indications and contraindications for enteral nutrition support (give at least 4 examples of each).

1. Pt who cannot meet nutritional needs via oral intake but has a functioning GI tract

2. Economical, yields effective nutrition utilization, maintains gut mucosal integrity, allows for trophic feeds, prevention of intestinal permeability

3. Contradictions:

3. List the access routes for enteral nutrition support.

Nasogastric tube, orogastric tube, gastrostomy, nasoduodenal, nasoenteric, or jejunostomy

4. What are the advantages of enteral vs. parenteral nutrition?

Enteral nutrition is less expensive, less risk of infection, and less risk of dehydration to patient. Also, the tube can be used to administer medications, is more easily removed, and can be done at home by pt more easily.

Pt is to start on a TF. Choose formula from list below. Justify your choice. Determine initiation, progression and goal rate of TF.

Formula A: 1.06 cals/cc, 37.1 gm pro/L, 84% H2O, 300 mOsm

Formula B: 1.06 cals/cc, 44.3 gm pro/L, 83.5% H2O, 300 mOsm, 14.1 gm fiber/L

Formula C: 1.3 cals/cc, 66.6 gm pro/L, 79% H2O, 385 mOsm, protein provided as peptides and free amino acids, 2% of cals as arginine

Formula D: 1.9 cals/cc, 62.5 gm pro/L, 83.7% H2O, 340 mOsm

Formula E: 2.0 cals/cc, 83.7 gm pro/L, 71.2% H2O, 690 mOsm

I would choose formula C. goal rate would be 70mL/hour to provide 2,184 calories, 112 grams protein, 1,327 mL free water. I would recommend 215 mL water flushes q 6 hours to provide a total of 2,187 mL water/day. I would recommend initiating the feedings at 30 mL/hour and advance by 10-15 mL q 8 hours to goal rate. I think this is the best formula choice because of the protein amount. This patient is requiring hirer protein needs and this is the best formula to meet his needs with giving excessive calories and fluid.

5. What are possible causes of the following GI complications of TF? What can be done to prevent these complications?

Nausea/vomiting: this could be caused by the rate being too fast. This can be prevented by slowing the rate of the TF, starting the TF and a slow rate and gradually increasing to goal rate, and if recurrent nausea with TF you could try cyclic feedings and feed pt while their sleeping.

High residuals: this can be caused by the TF not being properly digested by the patient, the patient could be positioned in a way that’s not allowing the TF formula to flow properly, and bolus feedings can cause high residuals. At my facility, two high residuals of over 250 in a 24 hour period is indicative of high residuals. When this occurs, we instruct the nursing staff to make sure pt is sitting up during feedings, possibly adjust the rate, and try adding Reglan.

Abdominal distention: this can happen if the TF is not being digested, over feeding the patient, or providing too much fluid. This can be fixed by adjusting the rate, adjusting the water bolus recommendations, trying a different route for the TF, or if necessary recommending TPN to give the gut rest.

Diarrhea: diarrhea can occur if pt is not tolerating the TF formula. This can be prevented with the use of a fiber added formula to bulk up the stool. If necessary, you can adjust the rate and/or formula to find one that is better tolerate such as an elemental formula.

Constipation: this can occur if the pt is not getting enough fluid. This can be fixed by increasing the water boluses, or switching to a formula with more fiber.

6. What problems are encountered when giving medications thru the feeding tube?

Medications can clog the tube, can be given at too fast of a rate, and medications should not be mixed with TF formula. Also, it is important for staff to consider where the tube is (ie jejunum, stomach) and where the medication is better absorbed to determine if administering through the tube is a good option.

7. What procedures are routinely used to prevent the occlusion of feeding tubes? How can clogged tubes be safely reopened?

Flushes are used not only to provide additional fluid to the pt but also to prevent the occlusion of feeding tubes. A clogged tube can be safely reopened by flushing with lukewarm water, gently massaging the tube while flushing, and clamping the tube for a few minutes allowing the water to “soak”.

Two weeks later, the patient has a PEG placed in preparation for being transferred to a rehab facility.

8. Is the current TF formula and rate still appropriate? If not, make new recommendations, including a bolus feeding schedule.

Caloric and fluid amounts are still appropriate for this pt. protein can be reduced to 1-1.2 g/kg IBW since the patient is off the ventilator. This would give a protein goal of 89-107 grams protein. The current feeding provided 104 grams of protein so this formula remains appropriate.

520 mL boluses 3 times per day with 135 mL flushes before and after feedings. This will provide the pt with 2,028 calories, 104 grams of protein, and 2,042 mL fluid including flushes.

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