Enteral Nutrition

1. George, age 89, has a PEG tube and receives a tube feeding of 90cc/hour over
24 hours of Jevity 1.2. He is currently at the hospital following a diagnosis of
esophageal stricture with dysphagia. The nursing staff is flushing the feeding
tube 3 times per day with 30 mL water to keep the line patent. What does this
provide?

_~2600__ Kcals
__~120__ Grams Protein
__2160___ Fluid mL EN
__805___ Total fluid with flushes
__~40__ Grams Fiber

If George is at his IBW of 80 kg and his estimated energy needs are 2000-2300
kcals, protein needs 95-115 grams, and fluid at 1800 mL/day, how would you
adjust his tube feeding to approximate his needs more accurately? Stick with the
Jevity 1.2. (You can either decrease the volume or recalculate from scratch)

Make sure to include:

__1800ml/day__Total Volume
__75 ml/hr/24hrs__Goal Rate
__2200 total and 27.5 per kg__Total kcals and kcals/kg
_100 g total 1.25 per kg_Total protein and grams/kg
__1450__ Fluid mL EN
__1800__ Total fluid with flushes
__(2) 175 ml flushes__ Number and volume of flushes

George will be going to the long-term care facility on tube feeding and the home
has asked that you transition George to bolus feedings before discharge.
Provide your recommendations below. Make sure you follow writing the
comprehensive order as presented in the PowerPoint.

Specifics ab bolus feeding ? switch to

440 ml bolus feedings five times a day when appropriate, advance to increasing
to 4 feedings of 550 ml at a time.

Goal tube feeding of:

1800 ml Jevity 1.2/day
Goal rate 75ml per hour continuous infusion over 24 hours
Start @ 40 ml per hour
Advance by 10ml/hour every 4-8 hours as tolerated to goal
Patient will need 350 ml additional fluid per day PO or as flushes to meet
maintenance fluid needs; can be given as 2, 175 ml flushes

EN provides:
 2200 kcals (27.5 kcals/kg)
100 grams protein (1.25 grams/kg)
1800 ml fluid with flushes

To avoid aspiration, what recommendations would you make in your note to

communicate with the nursing staff?

We need to communicate to the nurse that she/he must first raise the patient to a 30-
45° recumbent position during feeding and for 1 hour thereafter. Secondly, they should
Use intermittent or continuous feeding regimes rather than the rapid bolus method
whenever possible, and lastly, the gastric residuals should be checked regularly.

2. Doris, age 85, is already at the LTC facility as she had a stroke 3 years ago. She
has previously been taking a pureed diet and supplemental Ensure, but her
weight has dropped 12 pounds over the past 6 months. Doris now weighs 139
lbs and is 5’7” tall. All efforts at increasing her PO intake have been exhausted
and the resident physician has asked for an EN consult for “supplemental EN”.
Doris’s kcal counts the past week are averaging 600 kcals, 8 grams of protein,
with 200 mL water with meds. Her laboratory is consistent with mild dehydration.

What is Doris’s BMI? _21.8_ What range of BMI does this classify Doris?
Normal

Formulate a PES statement below that supports initiation of supplemental EN.

Inability to consume adequate nutrition orally due to post stroke complications resulting
in a weight loss of 12 pounds in 6 months.

Select an EN product that you feel is best for Doris. Provide a brief explanation
of why you have chosen this product.

I selected Osmolite because I did not want to shock Doris’s system too abruptly with an
overload of nutrients such as lipids since she has been in a starvation state due to her
inability to ingest an adequate amount of food due to her stroke. Also, I liked that the
water content was a little on the high range since she is dehydrated.

Estimate Doris’s kcal needs (standard –rule of thumb) (include range):

_1890__ Energy _30__ (kcal/kg)

Estimate Doris’s protein, kcal and fluid needs (Use Harris-Benedict for Energy):
__~1540__ Energy _ 24.44 (~25) __ (kcal/kg)
63 _ Protein __1__ (grams/kg)
_1540__ Fluids
 Make sure to include:
__ 1090___Total Volume
_ bolus feeding after each meal-time 4 times a day of 275 ML_Goal Rate or
Bolus schedule
__4 Bolus feedings per day with meals and snack_Schedule
__ to avoid refeeding syndrome start with smaller feedings and work up to larger
feedings.
_1370,~ 20 kcal/kg Total kcals and kcals/kg EN
__50~, ~.8 g/kg _Total protein and grams/kg EN
___800 ml_Fluid (if needed)
___~70 % (68%)__Percent of needs met by the supplemental tube feeding.

Doris may be at risk of refeeding syndrome. What factors from her history would
point to this?

Her current intake has put her body into the starvation state, dehydrated and she
has lost 12 lbs. in 6 months, which at her age is significantly more dangerous.

What laboratory tests should you request to further assess risk of refeeding?

We would want to test Doris’s electrolyte balance and specifically check phosphorus,
potassium, calcium, and magnesium levels.
Determine what each formula provides based on the information given.

Peptamin - 80ml/hour/24 hours provides:

__1920__kcals
_80~__grams protein
__75~_percent fat
__1630~__water

Pediasure – 6 feedings of 55 ml each with 30 ml flushes following each feeding

provides:
_330___kcals
_~10_grams protein
__~460 ml___water

Osmolite – 75ml/hour/12 hours provides:

___~950__kcals
_____~40__grams protein
___~130__total grams CHO
_____~760__water

Vital – 65ml/hour/24 hours provides:

_____1560__kcals
___~60__grams protein
_____~60__total grams fat
__1310~__water
___None__fiber