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NUT 116BL Name: Tess Soper

Winter 2015 Section: A01

Major Case Study: Enteral and Parenteral Nutrition

Due 2/13/15
60 points

Mr. R, a 35 yo drug user, is hospitalized after a motor vehicle accident (MVA). He is currently
suffering from a severe concussion and lapses of consciousness, a broken jaw, multiple broken
bones, and possible internal injuries. He had not eaten anything for several days PTA because he
was overdosing on drugs. Enteral feeding has been recommended in order to improve his
nutritional status and given his decreased level of alertness. The patient will be bedridden until
his mental status improves. A nasogastric feeding tube has been inserted and the physician has
asked for your recommendation regarding the type of formula and amounts of kcal/protein
needed for this patient.

Ht: 5’11” Current wt: 156 # UBW: 167 # Serum albumin: 3.0 mg/dL

1. Write 1 PES statement for this patient. (2 pts)

Inadequate energy intake (NI-1.2) R/T difficulty with self-feeding AED his broken jaw and lack
of consciousness.

2. Is the nasogastric feeding route appropriate for this patient? Why or why not? (3 pts)
When choosing a route of administration one should take into account how long the TF will be
necessary, if the GI works, the aspiration risk, and monitoring of location of tube.
This patient is not fully conscious which means he is at risk for high aspiration. I would
recommend a more appropriate tube feeding which would be a nasoduodenal (ND) tube, which
passes through the nose to the duodenum, which bypasses the stomach. A ND placement is used
if aspiration is high, reflux is high, and gastric emptying is slow. The patient also has a
functioning GI. It is correct to choose a short-term enteral feeding tube as his GL is functioning,
but he should receive a ND tube because his aspiration risk is high with his lack of
unconsciousness. Although we are unaware if the PT needs less than 4 weeks of therapy, the ND
would be the best choice.

3. What daily intake of kcals, protein, and fluids would you recommend for this patient and
why? Show calculations for estimated needs, give recommendations as kcal/d, g
protein/d, ml fluid/d. (6 pts)
Daily intake kcals:
70.9kgx25 kcal/g=1772.5=1800
70.9kgx30kcal/g=2127=2100
1800-2100 kcals

wt: 156lb/2.2lb/kg=70.9 kg
ht: 5’11’’= 5 ft x 12 in= 60 in+ 11in= 71 inches
71 inchesx2.54 cm
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=180.34 cm

(PR,6,9)
(Nutrition Therapy and Pathophysiology, 60)
Kcals Needs based on Mifflin St Jeor:
10(70.9kg) + 6.25 (180.34cm) – 5(35yrs) +5
=1666.125 kcal/d
Activity Factor: Confined to bed 1.2
Injury Factor: Skeletal trauma 1.2-1.4

1666.125kcal/dx1.2AFx1.2IF= 2399 kcal/d=2400kcal/d

1666.125kcal/dx1.2AFx1.4IF= 2799 kcal/d=2800 kcal/d
kcal needs: 2400-2800 kcal/d

(PR, 168)
Daily intake of protein:
Protein Requirements:
Recommended intake for wound healing: 1.2-1.5 gm/kg/d
70.9kgx1.2g/kg/d= 85.08 g pro/d= 85 g pro/d
70.9kgx1.5g/kg/d= 106.35 g pro/d= 106 g pro/d
85-106 g protein/day

Daily intake of Fluids:

1ml/kcal
2400-2800 ml fluid/d

The patient should receive 2400-2800 kcal/d because he is confined to his bed (AF=1.2) and has
severe skeletal trauma (IF=1.2-1.4). He should intake 85-106 g protein/d based on the
recommended intake for wound healing (1.2-1.5 gm/kg/d), and 2400-2800 ml fluid/d to based on
daily fluids needs of 1mL/kcal.

4. Based on the needs of this patient, describe three desirable characteristics for the type of
formula you would recommend. Give one example of an appropriate enteral formula
meeting these characteristics. Use Appendix C2 in NTP text or the formulary provided
on the UCD SmartSite. (4 pts)
(EN lecture, 116bl)
Three desirable characteristics for the type of formula I would recommend would include
whole proteins, low osmolality, and containing fiber. Because the patient has a
functioning GI, he will be able to digest the whole proteins on his own. Enteral feedings
should be isotonic with osmolality around 300 mOsm/L whenever possible. Lower
osmolality is best for intact proteins and large starch molecules (functioning GI tract).
The formula chosen should contain fiber to support normal bowel function and to reduce
the risk of constipation in his functioning GI tract. One appropriate enteral formula
meeting these needs would be Jevity (Abbott): 1.06 kcal/mL, 83 % H2O, 300 mOsm/kg,
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44 g protein/1000mL. Jevity contains whole proteins, has an osmolality of 300 mOsm/kg,
and contains fiber.

5. a) Based on the enteral formula you selected in question 3 above, what daily total volume of
formula would meet Mr. R’s estimated kcal and protein needs? Show calculations. (3 pts)

Jevity(Abbott): 1.06 kcal/mL, 83 % H2O, 300 mOsm/kg, 44 g protein/1000mL

Middle of kcal range: (2400+2800=5200/2=) 2600kcal/d

2600 kcal/d/1.06kcal/ml=2452.8mL formula/day
44g PRO/1000L= 0.044 g protein/mL
Protein: 2452.8 mL formulax0.044g PRO/mL= 107.9 g protein
(within requirement of +/- 10 grams)

b) What would be the hourly rate for delivery of this tube feeding as a continuous 24hr
infusion? Show calculations. (1 pt)

2452.8mL/24 hours= 102.2 mL/hour

c) Is this volume of tube feeding adequate to meet his fluid needs? If not, indicate what else is
needed and how it would be added to the current tube feeding. Show calculations. (4 pts)

His fluid needs are 2400-2800 mL/day. The average of these two fluid values is 2600mL/day.
This patient is given 2452.8 mL of formula that is 83 percent water. This means that the patient
is receiving (2452.8mLx.83=) 2035.8 mL of water per day. There is a deficit of (2600mL/d-
2035.8ml/d=) 564.2 mL of water per day. This patient will need free water flushes to make up
for the fluid he is not receiving from his formula. He should receive (564.2mL/6 times a day= )
94.0 mL free water flushes every 4 hours.

2400mL/d+2800mL/d= 5200mL/d/2= 2600mL/day

2452.8mLx.83=2035.8mL water/d
2600mL/d-2035.8mL/d=564.2mL/d
564.2mL/6 times per day= 94.0 mL free water flushes every 4 hours

6. Give 3 blood values that you would monitor for this patient and the reasons why. (6 pts)
(NTP,55)
Three blood values I would monitor for this patient would be blood glucose, albumin, and Pre-
albumin levels. I would monitor albumin levels because they can be affected by trauma and
metabolic stress and can affect hydration status. A primary function of albumin includes being a
component of electrolyte balance. The albumin level will increase with dehydration. Albumin
levels are also used for overall protein nutriture. I would want to make sure the patient is not
dehydrated as well as receiving adequate protein. I would monitor pre-albumin because these
levels decrease with infection, trauma, metabolic stress and decreases with diagnoses of liver
diseases such as cirrhosis, malabsorption, and hyperthyroidism. Pre-albumin appears to be a
consistent indicator for risk of malabsorption. I would want to make sure the patient is absorbing
the nutrients fed to him. I would monitor blood glucose to make sure the patient is receiving
proper insulin coverage if needed. If insulin is needed to control blood glucose levels, one can
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get the treatment they need. Blood glucose should be monitored in all patients receiving
aggressive nutrition supplementation to make sure they are receiving the correct amount of
dextrose. Also, hyperglycemia or high blood glucose may be associated with fluid and
electrolyte disturbances and increased infection risk.

7. Give one urine value that you would monitor and the rationale for monitoring it. (2 pts)
(NTP, 61)
I would monitor urinary urea nitrogen to measure urinary nitrogen concentration. Urine nitrogen
loss can be used to gauge the degree of stress and in comparison with nitrogen intake. UUN
checks one’s protein balance and the amount of food protein needed by ill patients. It is excreted
by the kidneys and can also indicate if the kidneys are working well. One would then be able to
monitor the patient’s nitrogen balance, which should be positive. Low levels can indicate kidney
problems or malnutrition (inadequate protein in the diet) and can represent catabolism while very
high levels can indicate increased protein intake in the body or too much protein intake. A
positive (not too high) nitrogen balance is consistent with anabolism and generally indicates the
patient is receiving adequate amounts of protein. Protein goals can be adjusted to accommodate
metabolic protein breakdown.

The patient, Mr. R, is now 5 days s/p his MVA. He did not tolerate the enteral feedings well
(diarrhea and pain) and now has been diagnosed with acute pancreatitis. The MD has ordered a
nutrition consult for evaluation of parenteral nutrition (PN) support. For the purposes of
answering questions 7-12, assume that your current estimated kcal and protein needs for Mr. R
are: 2600 kcal/day and 110 g protein/day.

8. Write a PES statement. (2 pts)

Inadequate intake from enteral nutrition (NI-2.3) R/T lack of toleration of feedings AEB
diarrhea, pain, and recently diagnosed acute pancreatitis.

9. Which type of PN support do you recommend – central or peripheral? Justify your answer. (2
pts)
(PN lecture, Nut 116bl)
I would recommend central vein feeding (CPN) because this patient has high caloric needs,
inability to tolerate enteral feeding (should be 7-10 days although he has only gone 5, one can
see enteral is not working for him), and risk of malnutrition due to acute pancreatitis. He also
may need this form of feeding for long term due to his mental status/consciousness. While the
patient did not tolerate the enteral feedings as seen with his diahrea and pain, his energy intake
was very low even though he has high caloric needs. Also, due to the calculations below, this
patient should be given CPN due to because PPN is restricted to less than 900 mOsm/L. CPN
would be required because mOsm restrictions for PPN. 550mOsm/L + 1206 mOsm/L =
1756mOsm/L (which is too high for PPN).

5.5% AAx100mOsm/L=550mOsm/L
24.1%dextrosex50mOsm/L=1206mOsm/L
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10. Calculate the amount of a 10% lipid emulsion that is needed to provide around 20% of Mr.
R’s total kcal needs. Show calculations. (2 pts)
(PN Lecture, Nut 116BL)
Kcal need = 2600 kcal x 0.20 fat from kcal = 520 kcal from fat
10% lipid emulsion: 1.1kcal/mL
520kcal form fat/ 1.1 kcal/mL = 472.72 ml= 473 mL of 10% lipid emulsion
Pt should be provided with a 500mL bag.

11. The MD wants the dextrose and amino acid solution to be a total volume of 2 L/day. (The
volume of lipid emulsion is separate from this 2 L.)
a) Determine the final amino acid concentration of this solution, which would supply 110 g
protein/day. Show calculations. (2 pts)
round to 500

110g pro/2000mL=0.055x100=5.5% amino acid solution

b) Determine the remaining kcals to be provided as CHO. Express your answer as kcals from
CHO and as grams of dextrose. Show calculations. (3 pts)

110g protein x 4kcal/g = 440 kcal

47.27g fat x 11kcal/g = 520 kcal
2600kcal–440kcal from protein–520kcal from fat= 1640kcal from CHO
1640kcal / 3.4 kcal/g dextrose = 482.4g dextrose

c) Determine the final dextrose concentration of the solution. Show calculations. (2 pts)

482.4g dextrose/ 2000 mL x 100% = 24.1% dextrose solution

d) If the PN solution had to be made from a starting stock solution of D50W (500 g dextrose in
1 L of water), what volume of this stock D50W would be needed to provide the grams of dextrose
that you calculated in question 9b above? Show calculations. (2 pts)

482.4g dextrose/500g = 0.9648x100 = 96.48% of the solution

1000ml x 0.9648 = 964.8ml stock
964.8 mL D50W solution needed to meet 482.4g dextrose requirement

e) Compare the grams of dextrose to be provided in this solution with the maximum glucose
infusion rate for Mr. R of 5 mg/kg BW/min. Would you make any changes to the PN solution
based on this information? Explain your rationale. If so, how would you change it? (2 pts)
482g dextrosex1000mg/g= 482000mg
5mg/kg BW/min
5mg/kg x 70.9kg/min= 354.5mg/min x 1440min/day = 510480 mg/day
510480mg/day / 1000mg/g = 510.48 g glucose/day max
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482.4g/day / 1440min/day = 0.335g/min x 1000mg/g = 335mg/min

335 mg/min/70.9kg BW =4.7mg/kg BW/min

Over a continuous 24 hours, the rate of dextrose given would be 4.7mg/kg BW/min, which is
less than the maximum rate of 5mg/kg BW/min. The amount of dextrose provided in the PN
solution is 482.4g, which is less than the maximum glucose infusion rate of 510.5 g/d. I would
not make any changes because the rate of 4.7mg/kg BW/min is less than the maximum rate of
5mg/kg BW/min. It would be a problem if this rate was greater than 5. But because it is within
the range, it is acceptable to keep this PN solution.

12. List three lab values that you would monitor for this patient and the reasons why. (6 pts)
(PN lectue, 116b)
Three blood values I would monitor would include plasma phosphate, magnesium, and
potassium values. This is because refeeding syndrome is characterized by the rapid fall of these
nutrients. I would choose these values to monitor because the patient had not tolerated his enteral
feedings and has diarrhea and pain. I would want to make sure he is not in a state of malnutrition
where with the parenteral feeding he could go into the refeeding syndrome, where he would be
receiving too many nutrients too fast. With subsequent refeeding after starvation (or not getting
enough nutrients for the past couple of days in this pt’s case) causes an increase in insulin release
and an increase shift in phosphate, glucose, potassium, magnesium, and water to intracellular
compartments resulting in edema. There is also a risk for hypophosphatemia, hypokalemia, and
hypomagnesaemia. By monitoring these values, I would be ensuring he is getting a gradual
increase in nutrients and is not at risk for some complications to occur.

13. Mr. R develops hyperglycemia while on PN support. Describe two actions you would
recommend to help lower blood glucose and achieve metabolic control of the patient. (2 pts)

1.Add regular insulin to the PN bag as needed to control blood glucose.

2.Can restrict the number of carbohydrates (dextrose monohydrate) given to the patient or switch
to a formula that has less carbs.

14. What is refeeding syndrome? Why is it important to monitor for refeeding syndrome in a
severely malnourished patient who is started on PN? (4 pts)
(PN lecture, 116b lecture slides)
Refeeding syndrome is defined as dangerous fluctuations in fluids and electrolytes that lead to
metabolic and neuromuscular problems. It may occur in severely wasted patients during the first
days/first week of nutrient repletion. Characteristics include low potassium, low phosphorus, low
magnesium, high CO2, generalized fatigue, muscle weakness, cardiac dysfunction, and potential
death. When an individual is fed an excessive amount of nutrients after being malnourished, a
sudden shift in electrolytes and fluids causing metabolic changes in the body. Patients at risk for
refeeding syndrome include malnourished patients, those with inadequate intake over several
days (poor appetite or result of feeding), and those who have had a long history of inadequate
intake. It is important to monitor refeeding syndrome in a severely malnourished patient who is
started on PN because while they are initially very malnourished, subsequent refeeding after
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starvation causes an increase in insulin release and an increase shift in phosphate, glucose,
potassium, magnesium, and water to intracellular compartments resulting in edema. There is also
a risk for hypophosphatemia, hypokalemia, and hypomagnesaemia. The patient will need to be
provided their PN support very slowly during the refeeding process and then gradually increase
the amount over time. It is dangerous to provide too many calories and too much fluid to a
person who has adapted to starvation.