NUT 116BL

Winter 2015

Name: ____Oi Yi Chan______

Section: ___A02_____
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: 511

Current wt: 156 #

UBW: 167 #

Serum albumin: 3.0 mg/dL

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

Swallowing difficulties related to the hospitalization after a motor vehicle accident as evidenced
by the severe concussion, lapses of consciousness and broken jaw. NC-1.1
2. Is the nasogastric feeding route appropriate for this patient? Why or why not? (3 pts)
Nasogastric feeding route is not an appropriate for the patient as the patient has lost his consciousness,
which leads to a high risk of aspiration and tube displacement. Nasogastric feeding is suggested only for
low aspiration risk patients. Also, a good GI function and low gag reflux are required for nasogastric
feeding, and there is no information about the patients GI function or gaga reflux.

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)
Kcal needs = Mifflin-St. Jeor Equation
= 9.99 x (156#/ 2.2046) + 6.25 x (180.34 cm) 4.92 x (35yo) +5
= 1666.83 kcal x AF (1.2) x IF (1.4)
= 2800 kcal

Protein needs = 1.5 g/kg/day x 70.76 kg to 1.7 g/kg/day x 70.76 kg

= 106 to 120 g
Fluid needs = 1 mL/ kcal x 2800 kcal
= 2800 mL

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)

High energy density: the patient needs a high kcal formulas to fulfill the requirement of 2800
kcal/ day
Moderate fiber: the patient had not eaten anything for several days, moderate fiber formulas
would help in prevent eternal tube feeding related diarrhea
Lactose-free: lactose may also cause diarrhea

Based on the desirable characteristics, Jevity 1.5 Cal would be an appropriate formulas.

5. a) Based on the enteral formula you selected in question 3 above, what daily total volume
of formula would meet Mr. Rs estimated kcal and protein needs? Show calculations. (3
pts)
Total volume of formula for kcal = 2800 kcal/ 1.5 kcal/ mL
= 1866.8 mL
= 1850 mL
Total volume of formula for protein = 1850 mL
= 1.85 L x 64 g/ L
= 118 g (fulfills the required amount of 106 to 120g)
Thus daily total volume of Jevity 1.5 in 1850 mL would meet Mr. R estimated kcal and protein needs.

b) What would be the hourly rate for delivery of this tube feeding as a continuous 24hr
infusion? Show calculations. (1 pt)
1850 mL/ 24hr
= 77 mL/ hr
= 75 mL/ hr (round to the nearest 5)
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)
The volume of tube feeding is not adequate to meet the fluid needs, additional fluid flush is needed.
Free water in Jevity 1.5 = 1850 mL x 76%
= 1406 mL free water
Additional fluid needs = 2800 mL 1406 mL
= 1394 mL/ 6 x
= 232.3 mL each
Flush with 250 mL free water every 4 hour.

6. Give 3 blood values that you would monitor for this patient and the reasons why. (6 pts)

Blood glucose: enteral feeding may cause hyperglycemia, thus it is important to maintain blood
glucose at or less than 110 mg/dL

Serum albumin: the blood albumin level of the patient is very low at 3.0 mg/dL (the
normal range is 3.5 - 5.0 g/dL), it indicates excess protein losses, malnutrition and
wasting.
Plasma electrolytes: the level of electrolytes such as sodium, potassium, magnesium and
phosphorus can reflect the possible metabolic complications of enteral feeding such as rapid
insulin-driven electrolyte uptake into cells.

7. Give one urine value that you would monitor and the rationale for monitoring it. (2 pts)
Urinary Urea Nitrogen (UUN) can be used for calculation for nitrogen balance during the feeding,
it is a test that measures the amount of nitrogen as a waste product resulting from the breakdown
of protein in the body. It is mainly used to check the patient's protein balance and determine how
much protein the patient takes in and needs.
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)
Initiation of parenteral nutrition related to intolerance of enteral feedings as evidenced by enteral
feeding related diarrhea and abdominal pain. ND-2.1
9. Which type of PN support do you recommend central or peripheral? Justify your
answer. (2 pts)
Central parenteral nutrition is recommended as the patients caloric needs is high (2600 kcal/ day), and
the parenteral feeding would be long-term as the patients has been diagnosed with acute pancreatitis and
pre-existing complications. Also, inappropriate peripheral vein nutrition may cause peripheral edema.

10. Calculate the amount of a 10% lipid emulsion that is needed to provide around 20% of
Mr. Rs total kcal needs. Show calculations. (2 pts)
10% lipid emulsion = 1.1 kcal/mL, 11 kcal/g
2600 kcal x 20% = 520 kcal from fat / 11 kcal/g
= 47.3 g fat
= 45 g fat (round to the nearest 5)
= 520 kcal/ 1.1kcal/ mL
= 472 mL of 10% lipid solution
= 500 mL of 10% lipid solution

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)
Final amino acid concentration = 110 g/ 2000mL x 100
= 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)
Kcal from protein = 110 g x 4 kcal/g
= 440 kcal
Kcal from fat = 45 g x 11 kcal/ g
= 495 kcal
Kcal from dextrose = 2600 kcal 440 kcal 495 kcal
= 1665 kcal CHO
= 490 g dextrose (1665 kcal/ 3.4 kcal/g)

c) Determine the final dextrose concentration of the solution. Show calculations. (2 pts)
Final dextrose concentration = 490g/ 2000mL x 100
= 24.48%
= 25% (round to the nearest 5)
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)
Volume of stock D50W need = 490 g dextrose x (1000 mL/ 500 g)
= 980 mL stock solution

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)
Maximum glucose infusion = 0.005g/ kg/ min x 70.76 kg x 1440 min
= 509 g
= 510 g (round to the nearest 0)
I would not make change to the PN solution as two solution are close to each other and the maximum
glucose infusion provides glucose more than requirement which may lead to hyperglycemia.

12. List three lab values that you would monitor for this patient and the reasons why. (6
pts)

Complete blood count (CBC): pancreatitis raise the number of white blood cell rapidly,
CBC can be used for monitoring the severity of pancreatitis, and it can also indicates
inflammation or infection.
Plasma glucose: pancreatitis can lead to unstable glucose level, close monitor on plasma
glucose can help in prevent hyperglycemia.
Bilirubin: both parenteral feeding and pancreatitis would raise the bilirubin level can
cause liver dysfunction, close monitor is suggested.

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)

Optimization of parenteral feeding carbohydrate content: modify the glucose infusion rate of

no more than 4 mg/kg/min or to lower the amount of infused dextrose to 150 to 200 g/d.

Insulin therapy: adding insulin into TPN feeding or use it separately to control hyperglycemia

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)
Refeeding syndrome is the dangerous fluctuations in fluids and electrolytes that lead to metabolic and
neuromuscular problems. The symptoms include low potassium, phosphorous, magnesium, high CO2,
fatigue, muscle weakness and potential death.
It may occur in severely malnourished patients during the start of nutrition repletion due to the high level
of CHO intake cause glycose and electrolytes to shift into the cells; high CHO infusion also stimulates
insulin and reduces Na and water excretion which leads to risk of fluid overload complications, fluids
cause expansion such as edema.