MEDICAL NUTRITION THERAPYCASE STUDY 1

GROUP MEMBERS:

NURNAIMAH MD KASSIM NUR KHAIRUNNISA JALALUDIN

FATIMAH AMIRAH ZAKARIA NOR FAIZAH MUSTAFA

Case Study 1

RK is a 25 years old man, who was involved in MVA. He had multiple fractures, contusions, and severe head injury. He was unconscious most of the time and being fed via nasogastric tube feeding. RK’s lab results were normal upon admission with exception of Hb (8.1 g/dL) and Hematocrit (31%). His height is 179 cm and weight is 80 kg, and he loss about 5 kg within 3 weeks of ICU stay. Currently he was on Ensure plus 50cc/Hr and physician is planning to insert PEG tube. Discuss the dietary care plan for RK’s current condition and after PEG tube was inserted.

PEG = Percutaneous Endoscopic Gastrostomy

Assessment

• Subjective DataName : RKAge : 25 years old Involved in MVA, had multiple fractures, contusions and

severe head injury.

• Objective DataHeight : 179cmWeight :80kg (loss 5kg within 3 weeks during ICU stay)BMI : 25kg/m²Dietary Being fed via nasogastric tube feeding (continuous feeding)Currently on Ensure Plus 50cc/hrBiochemical data

Data Result Normal range

Indication

Hemoglobin 8.1g/Dl 14-17g/dL Low ( loss many blood due to MVA)

Hematocrit 31% normal adult male range 41-53%)

Low ( loss many blood due to MVA)

PES Statement

Weight loss related to inadequate calorie intake as evidence by loss 5kg within 3 weeks of ICU stay.

Objectives & Principles

OBJECTIVES

1) To ensure adequate energy requirement meet.

PRINCIPLES• Calculate the estimated

energy requirement by considering his condition (on bed, unconscious, low blood count and bone fractures).

• Provide energy intake gradually (step by step until patient meet the adequate energy requirement).

OBJECTIVES

2) To provide nutrition support consistent with the patient’s nutritional status and available route of nutrient administration.

PRINCIPLES• To monitor either the patient

can tolerate the enteral feeding via PEG tube.

• To manage the enteral feeding of the patient from small amount of calorie intake after insertion of PEG tube due to post surgery condition.

OBJECTIVE

3) To maintain current body weight.

PRINCIPLE

• To provide the sufficient energy requirement base on his condition.

• To avoid lack or over feeding for the patient.

OBJECTIVE

4) To avoid and manage complications or infection related to the technique of nutritional delivery.

PRINCIPLE

• To educate the caregiver of the patient on the proper management and hygiene of the tube feeding.

• To monitor the progress and condition of the patient once a week.

• To educate the patients and caregiver about the possible complication and ways to overcome.

OBJECTIVE

5) To improve patient’s condition on low blood count and bone fractures.

PRINCIPLE

• To provide adequate nutrient like protein(0.05g/ml), calcium(0.8g/ml) , magnesium(0.4g/ml) and phosphorus(0.8g/ml) to improve the patient recovery.

Calculation of Energy Requirement

• Current BMI = 25kg/m² (overweight)• Energy requirement

Harris-Benedict Equation:

66+(13.7xWt)+(5xHt)-(6.8xA)

66+(13.7x80)+(5x179)-(6.8x25)

=1887kcal

TEE=BEE x AF( confined to bed) x IF (head injury)

1887x1.2x1.4

3170.16kcal/day ≈ 3100kcal/day

• Protein intake80kg x 1.6 (head injury) = 128g/day

Macronutrients Distribution.

• Energy requirement = 3100kcal

CHO 55% x 3100kcal = 1705 = 426.3g 4

Protein 128g x 4 x 100 = 17%3100kcal

Fat 28% x 3100kcal = 868 = 96.4g 9

Ensure plus (RTU)

Ensure plus Composition

Energy 1.5kcal/ml

CHO 0.2g/ml

Protein 0.05g/ml

Fat 0.05g/ml

Calcium 0.8g/ml

Phosphorus 0.8g/ml

Magnesium 0.4g/ml

Ensure Plus (RTU)

Step 1: 50ml/hour of Ensure Plus (RTU) (5hours+1hour rest)

Calorie = 250ml/5hrs x 1.5kcal/ml x 4feeding

= 1500kcal/day

Protein = 1000ml x 0.05g/ml

= 50g/day

If patient can tolerate 1-2 feeding, go to step 2.

Before and after feeding flush with 30ml water.

Step 2: 70ml/hour of Ensure Plus (RTU) (5hours+1hour rest)

Calorie = 350ml/5hrs x 1.5kcal/ml x 4feeding

= 2100kcal/day

Protein = 1400ml x 0.05g/ml

= 70g/day

If patient can tolerate 1-2 feeding, go to step 3.

Before and after feeding flush with 30ml water.

Step 3: 90ml/hour of Ensure Plus (RTU) (5hours+1hour rest)

Calorie = 450ml/5hours x 1.5kcal/ml x 4 feeding

= 2700kcal/day

Protein = 1800ml x 0.05g/ml

= 90g/day

If patient can tolerate 1-2 feeding, go to step 4.

Before and after feeding flush with 30ml water.

Step 4: 100ml/hour of Ensure Plus (RTU) (5hours+1hour rest)

Calorie = 500ml x 1.5kcal/ml x 4 feeding

= 3000kcal/day

Protein = 2000ml x 0.05g/ml

= 100g/day

If patient can tolerate 1-2 feeding, go to step 5.

Before and after feeding flush with 30ml water.

Step 5: Ensure Plus (RTU) (100ml/hr) + Myotein (4scoops)

*same as step 4 but we add with myotein (modular formula) in order to increase the protein intake and at the same time don’t want to add more calorie to the patient’s feeding.

Myotein Composition

Energy 30.1kcal/scoop

Protein 1scoop = 5g

If patient can tolerate 1-2 feeding, go to step 6.Before and after feeding flush with 30ml water.

Calorie = 500ml x 1.5kcal/ml x 4 feeding (Ensure Plus)

= 3000kcal/day

Total calorie = 100ml/hr Ensure Plus + 4scoops of Myotein

= 3000kcal + 120.4kcal

=3120.4kcal

Protein = 100g/day + 4 scoops of myotein

= 100g + (4x5g)

= 120g/day

Step 6: 100ml/hr of Ensure Plus (RTU) + Myotein (6 scoops)

Total calorie = 100ml/hr Ensure Plus + 6scoops of Myotein

= 3000kcal + 180.6kcal

=3180.6kcal ~ ACHIEVED!

Protein = 100g/day + 6 scoops of myotein

= 100g + (6x5g)

= 130g/day ~ ACHIEVED!

PEG tube feeding

• After PEG tube was inserted, start fed the patient with lower calorie in order to avoid

any complication after surgery. So, it is suggested to start from step 1 which is similar to

nasogastric tube. If patient can tolerate with 1-2 feeding, proceed to the next

step (step 2, 3,4,5 and 6) until achieved adequate energy requirement.

If patient cannot tolerate with feeding in certain step, back to the previous step.

Implementation

• Education for caregivers

i. Aware the hygiene aspect during preparation of blended diet for patient to avoid any infection occurred.

ii. Encourage caregivers to provide variety of food (blended diet) according to patient’s desire within recommended energy requirement.

iii. Flush the tube with 30ml of water before and after feeding in order to avoid clot.

iv. If caregivers can not afford to buy Ensure Plus, refer to Welfare unit for help.