Mary Fraser

NUTR-UE 1185.002
Clinical Nutrition Assessment and Intervention
Fall 2017

Paper 2: Enteral Feeding Practice; Use Emory Case 17;

Estimate the patient’s energy needs, indicate the method you used to do so, and briefly explain your choice.

56 yr old male
5’8” (using 1” = 2.54cm) à 68” x 2.54 = 173 cm= 1.73 m
ABW 165 lbs (using 1 lb = .454 kg) à165 x .454 = 75 kg
UBW 185 lbs (4 months ago) à 185 x .454 = 84 kg
% weight lost= 20/185 à 10.8% weight loss over 4 months = SEVERE weight loss
Current BMI: kg/m2 à 75/1.732 = 25 just at the edge of overweight status.

At this point we just want to keep his weight and nutrition stable, and not gain or lose weight. We don’t
want to overfeed the patient, as he is at risk for refeeding syndrome dysphasia and cancer cachexia, and
we also don’t want him to lose weight, but rather keep him stable. A high protein, high calorie diet, as
tolerated, is recommended for patients who are being treated with chemotherapy and radiation prior to
surgery.

We cannot use the Penn State equation because we don’t have the data for it, and don’t have IC. Using
the data at hand, the Mifflin St. Jeor Equation is the closest we can get to BMR and will adjust it slightly
with the modest sedentary activity level and coefficients. I will compare this calorie estimate with the rule
of thumb method.

As the patient is a drinker with 30 years of smoking, and is currently feeling weak, I would place his PA
level at sedentary, giving a PA coefficient of 1; As the patient is on the edge between normal and
overweight, but recently lost quite a bit of weight and has had trouble eating, I would use the equation
for TEE for Overweight or Obese Men over 19 years old with BMI ≥ 25 kg/m2.

TEE = 1086 – 10.1 x 56 yrs + 1 x (13.7 x 75kg + 416 x 1.73m) = 2267 cal/day; I will round to an estimated
2200 cal/day.

And, just to check, this is in line with the the rule of thumb method of 25-30 cal/ kg per day for critically ill
patients: 25 cal x 75 = 1875 cal/ day, and 30 cal x 75 = 2250 cal/ day; we get a range of 1875-2250 cal/day.

Estimate the patient’s protein and fluid needs and document what you are basing this on.

Estimated Fluid needs: fluid needs for ages 55-75 @ 30ml/kg à

30ml x 75kg= 2250 ml/day

Estimated Protein needs: should be higher because he is sick; Daily Protein Requirements for People with
Cancer: 1- 1.5 PRO g/kg a day à estimated 75-112 g PRO /day per 75 kg weight.

A. Using the NYP formulary (found in the EN/PN Lectures Resources folder), which formula is most appropriate for
this patient? Why? (10 points)

EN formula: Osmolite 1.5 cal.

 Vital 1.5 cal is an appropriate enteral formula for the patient’s medical conditions and nutritional needs
and is appropriate for the j-tube placement which is planned for after chemotherapy, radiation and
esophagectomy. We want to use as much of the GI as we can, instead of going the PN route.

Calculate the volume of feeding you would need to provide for your client’s energy and protein needs. Calculate an
appropriate flush (volume/frequency) to meet total fluid needs.

EN formula: Vital 1.5 cal.

Volume of feeding:
If we start with using 2200 cal/day as the # calories needed and / 1.5 cal/ml = 1466 ml/day à
61.08 ml/hr à round to 60 ml/hr
60 ml/hr x 24 hours = so will use 1440 ml formula per 24 hours
(Contains 76% water; .76 x 1440= 1094 ml water; 2250-1094 = 1156cc (round to 1200cc)
additional H2O needed; if flush 6x, that would be 200 cc per flush.
Flush: with 200cc H2O q4hrs.

Will provide: 2160 cal/day = 1440 x 1.5 (all in range of est. cal, fluid & PRO needs)
2294 ml/day fluids = (200cc x 6) + 1094 ml
97g PRO/day = 1440 ml x .0675 PRO g /ml

Choose the method of feeding [bolus/gravity drip/intermittent/continuous] for your patient while in the hospital
and explain why you made this choice.

As we will be using a Jejunostomy tube, continuous EN is appropriate. A continuous method is

recommended for patients with a risk of aspiration, a compromised GI function because of cancer therapy
and surgery, and when the tube placement is in the small intestine.

Write out the tube feeding regimen listing total mL of formula, total kilocalories, protein, free fluids, % RDI of
vitamins and minerals you are providing and total volume of regimen.

Feeding route: J-tube

Enteral Formula: Vital 1.5 cal.
Feeding Regimen:
Using a 24-hour feeding:
Vital 1.5 cal. via J-tube @ 60 cc/hr GOAL x 24hrs.
Start at 25 cc/hr, advance by 10-20 cc/hr q8-12hrs, as tolerated, until goal rate is reached. Flush with
200cc H20 q6hrs. Maintain aspiration precautions and adjust for residuals >500cc. Provides a 24hr. total
of: 1440mL formula, 2160 cal/day, 97g PRO /day, 2294 ml/day free fluids, 144% RDI of vitamins and
minerals. 24 hr total volume of feeding regimen is: 1440 ml Vital 1.5 total per 24 hrs +1200 cc H2O in
flushes. Keep head of bed elevated 30 - 45 degrees.

Nutrition Assessment:
History:
56 yr old male, appears weak and uncomfortable; suffering from Esophageal cancer, malnutrition, and
recent rapid weight loss; will have surgery, chemotherapy and radiation; Pt was a pack a day smoker for
30 years and 3-4 martinis on weekends; has a history of GERD, Barrett’s esophagus. Pt is also currently
suffering from coughing (2 months), sore throat, and difficulty swallowing with both solids and liquids;
Dysphagia and odynophagia; Nausea and early satiety also limits his food intake.

Anthropometric Measurements:
5’8” (using 1” = 2.54cm) à 68” x 2.54 = 173 cm= 1.73 m
ABW 165 lbs (using 1 lb = .454 kg) à165 x .454 = 75 kg
 UBW 185 lbs (4 months ago) à 185 x .454 = 84 kg
% weight lost= 20/185 à 10.8% weight loss over 4 months = SEVERE weight loss
Current BMI: kg/m2 à 75/1.732 = 25 just at the edge of overweight status.

Medications & supplements:

IV fluids
Full liquid diet as tolerated
Ondansetron
Hydromorphone
Lansoprazole

Biochemical data, medical tests, procedures:

Biopsy of distal esophagus and gastroesophageal junction: Adenocarcinoma
Chemotherapy: 5-Fluorouracil, cisplatin
Radiation
Esophagectomy
J-tube placement

Albumin 2.9 mg/dL low

PreAlbumin 8 mg/dL low
Hemoglobin 13.8mg/dL slightly low

Nutrition-focused physical findings:

Patient appears weak and uncomfortable; has a sore throat, cough, odynophagia, dysphagia.
Functional oropharyngeal swallow
Mod-severe esophageal dysphagia
Delayed movement upper esophagus with reflux into pharynx

Food/Nutrition Related History:

IV fluids
Full liquid diet as tolerated
Recently only eating small amounts of scrambled eggs, oatmeal, apple juice, canned peaches and soup.

Nutrition Diagnosis:
Chronic disease or condition related malnutrition, related to adenocarcinoma of the distal esophagus and
gastroesophageal, as evidenced by recent weight loss.

Nutrition Intervention:

Nutrition Prescription:
1. J-tube placement for Enteral Nutrition feeding
2. Using a 24-hour continuous feeding:
Recommend: Vital 1.5 cal. via J-tube @ 60 cc/hr GOAL x 24hrs.
Initiate at 25 cc/hr, and advance by 10-20 cc/hr q8-12hrs, as tolerated, until goal rate is reached. Flush
with 200cc H20 q6hrs. Provides a 24hr. total of: 1440mL formula, 2160 cal, 97g PRO, 2294 ml H2O, 144%
RDI of vitamins and minerals.
3. Maintain aspiration precautions and adjust for residuals >500cc.
4. Keep head of bed elevated 30 - 45 degrees.

Coordination of Nutrition Care:

1. Team meeting
2. Collaboration with other providers
 - MDs
-RNs
-Speech Pathologists

Counseling & Nutrition Education:

1. Provide education re: enteral nutrition provided to pt and/or family members
2. How to keep area of Feeding tube clean.
3. Defer more extensive nutritional counseling and education to later date due to current
clinical status.

Monitoring & Evaluation:

Goals: Maintain weight within +/- 2% of current body weight
Monitor albumin and prealbumin to get into normal range
Patient is able to consume adequate nutrition intake/hydration via the EN j- tube
Tolerates EN with no GI issues
As patient heals from surgery, monitor GI healing and function and re-evaluate EN type and prescription;
Reassess every 7 days.
Modify prescription if lack of progress.