Case Study 2: Tube Feeding Case Study

JB is a 45 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 inury. He was chemically
sedated using !iprovan "#ropofol$ at 5ml%hr. &nable to take foods orally, a nasogastric tube was
inserted for feeding. 'ull strength Jevity (.) at )* ml%hour was ordered initially, and then
advanced )* ml every + hours to the rate of 5* ml%hr which was prescribed by the physician. JB
had mild diarrhea when the tube feeding was first initiated, but this resolved after ) days. ,t the
time of admission, JB was 5-+. tall and weighed (/0 lbs, his usual body weight.
1wo weeks later, JB, has been weaned off of sedation and is transferred to the 2eurology unit. By
this time he weighed (53 lbs. , #45 tube was inserted one day prior to his transfer to the
2eurology unit.
6ne week later "three weeks after initial inury$, the speech therapist determines JB is regaining
his ability to swallow. 7he recommends that JB is placed on a pureed diet. JB8s social worker is
trying to transfer him to a rehabilitation facility "rehab$. 9n order to be accepted at this facility, JB
must be able to participate in therapies to relearn activities daily living ",!:8s$.
Objective Data
5ender; <ale
,ge; 45 years
Height; 5-+.
=eight. "admit$; (/0 lb.
=eight. "transfer$ (53 lb.
&B=; (/0 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
Pralb!m"#
3.$ mEq/L
)* mg%dl
4.0 mEq/L
12 mg/dl
3.$-5.2 mEq/L
18-35 mg/dl
Type your answers for the following >uestions. #lease submit this case study
online through Blackboard and bring a paper copy to class. 4nsure that all pages
of the paper of fastened together with a staple or binder clip.
(. =hy was JB placed on a tube feeding and not total parenteral nutrition when he was
admitted to the hospital?
JB8s gut was uninured and still working when he entered the hospital. 9t is best
to keep the gut working if it is working. 1ube feeding is also less e@pensive then
total parenteral nutrition.
). JB initially had some diarrhea. =hy did this occur?
, small amount of diarrhea is normal while the gut adapts to digesting the
formula.
A. =hat complications would you watch for while JB is on a nasogastric feeding?
=e should watch out for clogging of the tube, nasal necrosis, sinusitis, and
aspiration of formula.
4. Balculate ideal body weight "9B=$ for JB. Balculate his C9B= at admission and
when he was transferred to the neurology unit. Balculate his C&B= at transfer.
<ale; 9B= "kg$ D height "cm$ E (** E FGheight "cm$ E (5*H%4I D
9B= D (0).0 - (** - FG(0).0 - (5*H % 4I D 0).0 - 5./+ D /0.*) kg
admission weight D 05.0 kg
transfer weight D 0) kg
,dmission C9B= D BB= % 9B= D 05.0 % /0.*) @ (** D ((AC
1ransfer C&B= D 0) % 05.0 @ (** D 35C
5. ,t admission, were there any concerns regarding JB-s nutritional status based on his
body weight and labs? ,t the time of transfer to the neurology unit? "in other words, what
is your assessment of his nutritional status$.
,t admission JB8s lab data doesn8t raise any concerns. His B<9 is )5.4, which is
ust slightly overweight. 9 don8t see anything nutrition related to be really
concerned about at admission.
,t transfer there are some concerns like JB8s hematocrit level is now low-normal
and his hemoglobin is low, which can indicate anemia. His albumin and
pre-albumin levels are both low, which could indicate protein-energy
malnutrition.
/. Balculate JB-s caloric needs at admission and upon transfer to the neurology unit.
"&se kcal%kg and a predictive e>uation$.
Balorie needs at admission 0/.0 kg @ )5 kcal D (3(+ @ (.) "stress factor$ D )A*)
Balorie needs at transfer 0) kg @ A* kcal D )(/* @ (.) "stress factor$ D )53)
kcal%day D (*"wt$ J /.)5 "ht$ - 5"age$ J 5 D
kcal%day admission D (* "05.05$ J /.)5 "(0A$ - 5 "45$ J5 D050.5 J (*+( - ))5 J 5
D (/(3
kcal%day transfer D (* "0)$ J /.)5 "(0A$ - 5"45$ J 5 D 0)* J (*+( - ))5 J 5 D
(5+(
0. Balculate JB-s protein needs at admission and upon transfer to the neurology unit
"Justify your numbers$
#rotein needs at admission D 05.05 kg @ .+ g%kg to ( g%kg D /*./ g to 05.05 g
#rotein needs at transfer D 0) kg @ (.) g%g to ) g%kg D +/.4 g to (44 g
+. Balculate JB-s fluid needs at admission and upon transfer. ,re his fluid needs being
met by the tube feeding? 9f not, what would you change? "both admission and transfer$
'luid needs at admission D )5 m:%kg D 05.05 kg @ )5 m:%kg D (+34 m:
'luid needs at transfer D 0) kg @ )5 m:%kg D (+** m:
3. Balculate the calories provided to JB from the medication !iprovan.
(.( kcal%m: @ 5 m:%hr D 5.5 kcal per hour
(*. How many calories and grams of protein was JB receiving while on his tube feeding
of Jevity (.) at 5* ml%hr? =ere the tube feeding recommendations ade>uate to meet JB-s
needs while in the intensive care unit? 9f not, what would you recommend for a tube
feeding rate and product once JB was transferred to the 2eurology unit?
(.) kcal%m: @ 5* m:%hr D /* kcal%hour @ )4 hour%day D (44* kcal%day
55.5 g protein%liter % (*** ml D *.*555 g%m: @ 5* m:%hr D ).005 g%hr @ )4 hr
D//./ g%day
He needed at least )** more calories at both admission and at transfer. He also
could have used more protein even though he fell midrange in what he needed at
admission. 9 would switch him to the Jevity (.5 and slow the tube feed down to
45 m:%hr. He definitely needs more protein too. 1he Jevity (.5 gives *.*/A+
protein per m: @ 45 D ).+0%hr @ )4 hr D /3 g protein per day. /3 g - (** g "what
he needs$ D -A( g. JB will need 5 scoops of beneprotein per day.
((. =hat is the reason for starting the tube feeding at a slow rate?
9t takes time to get the body accustomed to an all li>uid diet like this. 1he
osmolality is not e@actly what the 59 tract is accustomed to. 9t takes time to get
the 59 tract to take the formula and get used to the osmolality.
(). How will you change his tube feeding order to prepare him for transfer to rehab?
4@plain your answer.
45 m: Jevity (.5%hr with ( scoop benepro in (** m: 5 @ day. ()5 m: H)* flushes
every / hours.
.0/ m: water % m: @ (*+* m:%day D +)*.+ m: water%day - (+** m: D 303 - 5**
D 403 m: water needed.
JB needs more calories and more protein to gain some of the weight back and to
no longer have protein-energy malnutrition.
(A. 6nce JB has been at rehab for A days, he is eating poorly. =hat should the rehab
dietitian do? 4@plain your answer.
JB has a #45 tube in his stomach that can help him eat better. He seems to need
more attention and assistance in eating. ,re there things that he can eat by
mouth? <aybe popsicles would be good for him. He8s probably missing having
food in his mouth.
(4. =rite one #47 statement appropriate for the time of transfer to rehab.
:ess than optimal enteral nutrition composition or modality related to protein
energy malnutrition as evidenced by weight loss and low albumin and pre
albumin blood levels.