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Enteral Nutrition: A Clinical Case Study using the Nutrition
Care Process
By Yingying YipFebruary 25, 2015
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Outline
Introduction of enteral nutrition Feeding tubes Types of formula Indications of EN Complications
Dysphagia and Aspiration
Clinical Case Study Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring & Evaluation Nutrition Follow-Up
Outcomes and Lessons
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Enteral Nutrition
Provides nutrients into the GI tract using a tube The tube is usually placed into the stomach, duodenum
or jejunum via either the nose, mouth or the direct percutaneous route
Can be used in combination with oral and/or parenteral nutrition
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Feeding Tubes
Nasogastric/Orogastric/Nasojejunal (NG/OG/NJ) Temporary, <30 days
Gastrostomy (GT) Long term Done in the OR, more invasive via laparotomy
Percutaneous endoscopic gastrostomy or jejunostomy (PEG/PEJ)
Long term Endoscopically using transillumination to make incision
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Percutaneous Endoscopic Gastrostomy
An endoscopic operation in which a feeding tube is placed through the abdominal wall and into the stomach
Allows nutrition, fluids, and medications to be administered directly into the stomach through the tube.
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Enteral Formulas
Standard/polymeric Contains intact nutrients: intact GI tract
Elemental Completely hydrolyzed nutrients: malabsorption
Disease specific For organ dysfunction or specific metabolic conditions: renal,
trauma/burns
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Indications for EN
“If the gut works, use it.” Functional GI tract but oral intake may not be possible,
adequate, or safe Malnourished or at risk of malnutrition Prolonged poor appetite Impaired swallowing function Conditions: anorexia, dysphagia, esophageal obstruction,
esophageal dysmotility, reduced level of consciousness, short bowel syndrome(more than 100 cm of jejunum)
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Complications
Necrotizing fasciitis Intraperitoneal bleeding Bowel perforation Septicemia Aspiration pneumonia Buried bumper
syndrome
Skin abscess Cellulitis Tube blockages Tube falling out Leakage of gastric contents
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Dysphagia
Swallowing difficulty Pain while swallowing, unable to swallow liquids and
foods safely Texture-modified diet and/or thickened liquids
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Aspiration
A condition when foods or fluids go into the lungs instead of the stomach
Cough in order to clear the food or fluid out of their lungs aspiration pneumonia
Eating becomes a big challenge for people with dysphagia and people who are at risk for aspiration
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CLINICAL CASE STUDY
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Methodology
Data were collected from: Patient’s medical record Interview with patient
Discussed nutrition plan of care with physician and nurse
Initial nutrition assessment and follow-ups
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Nutrition Assessment
JB: 92 year old male admitted with inability to take adequate oral nutrition, aspiration pneumonia, and features of hypovolemia
Underwent percutaneous endoscopic gastrostomy (PEG) tube placement and started tube feeding
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PMH
Venous insufficiency, peripheral neuropathy, osteoarthritis, GERD, hyperlipidemia, atrial fibrillation, CAD, DM, osteoporosis, HTN, BPH
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Nutrition Assessment – Food/Nutrition History
No known food allergies Coughed when he ate for the past six months and avoided the
dining room Speech-language pathologist: allowed for small sips of water
and possibly pureed diet for pleasure feeds post PEG placement
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Nutrition Assessment - Physical Exam
Alert and oriented x3 Skin warm and dry Abdomen soft
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Nutrition Assessment - Social and Family History
JB - pharmacist, married Daughter-in law - ophthalmologist Son - rheumatologist Expressed concerns over the procedure, types of tube feeding
formula, and new lifestyle adaptations Full resuscitation until conditions of advanced directives apply
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Nutrition Assessment – Anthropometric measurement
Height: 69 in / 175 cm Weight: 188.5 lbs / 85.7 kg BMI: 28 IBW: 172 lbs / 78.2 kg
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Nutrition Assessment – Nutrient Needs
Estimated energy needs: 20-25kcal/kg (20-25kcal) * (85.7kg) = 1700kcal - 2100kcal
Protein: 1 – 1.2g/kg 85-100 g protein / day
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Nutrition Assessment – Biochemical Data
Reference range
2/1 2/2 2/3 2/4 2/5 2/6 2/7 Reason for Abnormality
Sodium (mMol/L)
135-145 136 138 138 139 139 141 140
Potassium (mMol/L)
3.8 - 5 4.4 3.7 3.7 3.4 3.8 3.2 3.3 Decreased w/ diarrhea, K depleting diuretics
Glucose (mg/dL)
70-90 121 126 135 114 133 113 113 DM
Glucose POCT
93-189 mg/dL DM
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Nutrition Assessment – Biochemical Data
Reference range
2/1 2/2 2/3 2/4 2/5 2/6 2/7 Reason for Abnormality
BUN (mg/dL) 8-22 29 23 17 15 19 19 20 Renal insufficiency, dehydration
Creatinine (mg/dL)
0.4-1.2 1.3 1.1 1 1.1 1.2 1.1 1 Renal insufficiency, dehydration
Phosphorous (mg/dL)
2.4-4.3 2.3 2.1 2 Possible refeeding syndrome
Magnesium (mg/dL)
1.3-2.1 1.8 1.7 1.6
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Medications
Medications Action Side Effect/Nutrition Implication
Amlodipine antihypertensive Decrease Na may be recommended
Metoprolol antihypertensive Dry mouth, diarrhea, N/VAzithromycin antibiotic DiarrheaSSI antidiabetic Hypoglycemia
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Medications
Medications Action Side Effect/Nutrition Implication
PPI Anti-ulcer, anti-gerd May decrease absorption of Fe, vit B12
Zosyn Antibiotic diarrhea
KCl Electrolyte GI irritation, N/V, diarrhea
Lasix Diuretic Decrease K level in blood
Probiotic Biotherapeutic agent Help restore gut microbiome
Prescribed during this hospital stay:
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Initial Nutrition Assessment
NPO except for sips of water and medications for PEG placement
Poor PO intake PTA Concerned about the volume per feed, calories, and delivery
methods JB preferred to start on bolus feeds freedom of movement Physician: expected JB to be d/c soon, d/c with bolus feeds,
start with bolus feeds to assess tolerance Basic metabolic panel, Mg, and Phos ordered
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Nutrition Diagnosis - PES
Inadequate oral intake related to swallowing dysfunction as evidenced by poor PO intake PTA and patient NPO
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PES – Inadequate oral intake
Goal: patient to meet nutritional needs via total enteral nutrition with tolerance
Intervention: Jevity 1.2 bolus feed via PEG: 2 cans at breakfast, 2 cans at lunch, 2 cans a dinner, 1 can 2-3 hours after dinner feed (total 7 cans daily); 100mL free water flush before and after each feed (200mL per meal, total 800mL free water flushes)
Total nutrition provided: 1995kcal, 93g protein, 2137 cc fluid
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Nutrition Monitoring and Evaluation
Indicator: Enteral nutrition Criteria: tolerate bolus feed at goal
Indicator: Electrolytes and renal profile Criteria: WNL
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NUTRITION FOLLOW-UPS
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Nutrition Follow-up #1
JB w/ pleural effusion. Had diarrhea after each feed, refused feeding that morning. Formula changed to Osmolite 1.2. Free water flush decreased.
Nutrition dx: 1) Inadequate oral intake --- regressing 2) Altered GI function related to new PEG as evidenced by diarrhea after each
feed Nutrition prescription: Osmolite 1.2 bolus feed via PEG: 2 cans at
breakfast, 2 cans at lunch, 2 cans a dinner, 1 can 3 hours after dinner feed (total 7 cans daily); 50mL free water flush before and after each feed (100mL per meal, total 400mL free water flushes) --- to provide 1995 kcal, 92g protein, 1765 mL free water
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Formulas used in this case study
Jevity 1.2 high-protein, fiber-fortified formula
Osmolality, mOsm/kg H2O: 450
18 g fiber in 1000mL
Osmolite 1.2 high-protein, low-residue formula
Osmolality, mOsm/kg H2O: 360
No fiber
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Thoracentesis done and 1200cc of fluid removed Still had diarrhea Space out the tube feed to improve tolerance Administer a probiotic to balance the antibiotics Decrease volume to 6 cans/day
Nutrition prescription: Osmolite 1.2 bolus feed via PEG: 1 can each on following schedule: 8am, 9am, 12pm, 1pm, 5pm, 6pm (total 6 cans/day); 75mL free water flush after each feed (75 mL per feed, total 450 mL Free water flush) --- to provide 1710 kcal, 80g protein, 1620 mL free water
Nutrition Follow-up #2
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Nutrition Follow-ups
#3 JB’s diarrhea had improved MD ordered a test to rule out C. difficile infection
#4 Day of Discharge Tube feeding order was canceled accidentally Jevity 1.2 was sent and administered Resent Osmolite 1.2
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Outcomes
JB still had diarrhea at discharge but it had improved Tolerated Osmolite 1.2 bolus feed, 6 cans per day with 75mL
free water flush after each feed Provide 1710 kcal, 80g protein, 1620 mL water
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Lessons
Diabetes-specific enteral formula Tube feeding complications Continuous tube feed vs Bolus feed
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References Bankhead, R., Boullata, J., Brantley, S., Corkins, M., Guenter, P., Krenitsky, J., et al. (2009). Enteral Nutrition
Practice Recommendations. Journal of Parenteral and Enteral Nutrition. Botterill, I., Miller, G., Dexter, S., & Martin, I. (1998). Deaths after delayed recognition of percutaneous endoscopic
gastrostomy tube migration. British Medical Journal. Clearinghouse, N. I. (2010, October). Dysphagia. Retrieved from NIDCD:
http://www.nidcd.nih.gov/health/voice/pages/dysph.aspx Kirby, D. F., & Delegge, M. H. (1995). American Gastroenterological Association Medical Position Statement:
Guidelines for the Use of Enteral Nutrition. American Gastroenterological Association. Lloyd, D., & Powell-Tuck, J. (2004). Artificial Nutrition: Principles and Practice of Enteral Feeding. Clin Colon Rectal
Surg. Lo¨ser, C., Aschl, G., Hebuterne, X., Mathus-Vliegen, E., Muscaritoli, M., Niv, Y., et al. (2005). ESPEN guidelines on
artificial enteral nutrition - Percutaneous endoscopic gastrostomy (PEG). Clinical Nutrition. Lynch, C., & Fang, J. (2004). Prevention and Management of Complications of percutaneous Endoscopic
Gastrostomy (PEG) Tubes. NUTRITION ISSUES IN GASTROENTEROLOGY. McMahon, M., Nystrom, E., Braunschweig, C., Miles, J., & Compher, C. (2012). A.S.P.E.N. Clinical Guidelines:
Nutrition Support of Adult Patients With Hyperglycemia. Journal of Parenteral and Enteral Nutrition. Stroud, M., Duncan, H., & Nightingale, J. (2003). Guidelines for enteral feeding in adult hospital patients. Gut. http://www.summitgastro.com/endoscopic-procedures/peg-placement
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Thank You!
Any Questions?
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Delivery Methods
Continuous Uses a pump, low infusion rate Ideal for inpatient, bedbound, high aspiration risk, acutely ill
Bolus Uses a syringe, administer 240-480ml in 5-20mins Ideal for those living at home allows freedom of movement Rapid infusion may cause GI intolerance
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Complications
Diarrhea/constipation/nausea/vomiting Distention/bloating/cramping Aspiration Dehydration/overhydration Malabsorption/maldigestion Hyperglycemia Refeeding syndrome