case-study-1-q3
TRANSCRIPT
MEDICAL NUTRITION THERAPYCASE STUDY 1
GROUP MEMBERS:
NURNAIMAH MD KASSIM NUR KHAIRUNNISA JALALUDIN
FATIMAH AMIRAH ZAKARIA NOR FAIZAH MUSTAFA
Case Study 1
RK is a 25 years old man, who was involved in MVA. He had multiple fractures, contusions, and severe head injury. He was unconscious most of the time and being fed via nasogastric tube feeding. RK’s lab results were normal upon admission with exception of Hb (8.1 g/dL) and Hematocrit (31%). His height is 179 cm and weight is 80 kg, and he loss about 5 kg within 3 weeks of ICU stay. Currently he was on Ensure plus 50cc/Hr and physician is planning to insert PEG tube. Discuss the dietary care plan for RK’s current condition and after PEG tube was inserted.
PEG = Percutaneous Endoscopic Gastrostomy
Assessment
• Subjective DataName : RKAge : 25 years old Involved in MVA, had multiple fractures, contusions and
severe head injury.
• Objective DataHeight : 179cmWeight :80kg (loss 5kg within 3 weeks during ICU stay)BMI : 25kg/m²Dietary Being fed via nasogastric tube feeding (continuous feeding)Currently on Ensure Plus 50cc/hrBiochemical data
Data Result Normal range
Indication
Hemoglobin 8.1g/Dl 14-17g/dL Low ( loss many blood due to MVA)
Hematocrit 31% normal adult male range 41-53%)
Low ( loss many blood due to MVA)
PES Statement
Weight loss related to inadequate calorie intake as evidence by loss 5kg within 3 weeks of ICU stay.
Objectives & Principles
OBJECTIVES
1) To ensure adequate energy requirement meet.
PRINCIPLES• Calculate the estimated
energy requirement by considering his condition (on bed, unconscious, low blood count and bone fractures).
• Provide energy intake gradually (step by step until patient meet the adequate energy requirement).
OBJECTIVES
2) To provide nutrition support consistent with the patient’s nutritional status and available route of nutrient administration.
PRINCIPLES• To monitor either the patient
can tolerate the enteral feeding via PEG tube.
• To manage the enteral feeding of the patient from small amount of calorie intake after insertion of PEG tube due to post surgery condition.
OBJECTIVE
3) To maintain current body weight.
PRINCIPLE
• To provide the sufficient energy requirement base on his condition.
• To avoid lack or over feeding for the patient.
OBJECTIVE
4) To avoid and manage complications or infection related to the technique of nutritional delivery.
PRINCIPLE
• To educate the caregiver of the patient on the proper management and hygiene of the tube feeding.
• To monitor the progress and condition of the patient once a week.
• To educate the patients and caregiver about the possible complication and ways to overcome.
OBJECTIVE
5) To improve patient’s condition on low blood count and bone fractures.
PRINCIPLE
• To provide adequate nutrient like protein(0.05g/ml), calcium(0.8g/ml) , magnesium(0.4g/ml) and phosphorus(0.8g/ml) to improve the patient recovery.
Calculation of Energy Requirement
• Current BMI = 25kg/m² (overweight)• Energy requirement
Harris-Benedict Equation:
66+(13.7xWt)+(5xHt)-(6.8xA)
66+(13.7x80)+(5x179)-(6.8x25)
=1887kcal
TEE=BEE x AF( confined to bed) x IF (head injury)
1887x1.2x1.4
3170.16kcal/day ≈ 3100kcal/day
• Protein intake80kg x 1.6 (head injury) = 128g/day
Macronutrients Distribution.
• Energy requirement = 3100kcal
CHO 55% x 3100kcal = 1705 = 426.3g 4
Protein 128g x 4 x 100 = 17%3100kcal
Fat 28% x 3100kcal = 868 = 96.4g 9
Ensure plus (RTU)
Ensure plus Composition
Energy 1.5kcal/ml
CHO 0.2g/ml
Protein 0.05g/ml
Fat 0.05g/ml
Calcium 0.8g/ml
Phosphorus 0.8g/ml
Magnesium 0.4g/ml
Ensure Plus (RTU)
Step 1: 50ml/hour of Ensure Plus (RTU) (5hours+1hour rest)
Calorie = 250ml/5hrs x 1.5kcal/ml x 4feeding
= 1500kcal/day
Protein = 1000ml x 0.05g/ml
= 50g/day
If patient can tolerate 1-2 feeding, go to step 2.
Before and after feeding flush with 30ml water.
Step 2: 70ml/hour of Ensure Plus (RTU) (5hours+1hour rest)
Calorie = 350ml/5hrs x 1.5kcal/ml x 4feeding
= 2100kcal/day
Protein = 1400ml x 0.05g/ml
= 70g/day
If patient can tolerate 1-2 feeding, go to step 3.
Before and after feeding flush with 30ml water.
Step 3: 90ml/hour of Ensure Plus (RTU) (5hours+1hour rest)
Calorie = 450ml/5hours x 1.5kcal/ml x 4 feeding
= 2700kcal/day
Protein = 1800ml x 0.05g/ml
= 90g/day
If patient can tolerate 1-2 feeding, go to step 4.
Before and after feeding flush with 30ml water.
Step 4: 100ml/hour of Ensure Plus (RTU) (5hours+1hour rest)
Calorie = 500ml x 1.5kcal/ml x 4 feeding
= 3000kcal/day
Protein = 2000ml x 0.05g/ml
= 100g/day
If patient can tolerate 1-2 feeding, go to step 5.
Before and after feeding flush with 30ml water.
Step 5: Ensure Plus (RTU) (100ml/hr) + Myotein (4scoops)
*same as step 4 but we add with myotein (modular formula) in order to increase the protein intake and at the same time don’t want to add more calorie to the patient’s feeding.
Myotein Composition
Energy 30.1kcal/scoop
Protein 1scoop = 5g
If patient can tolerate 1-2 feeding, go to step 6.Before and after feeding flush with 30ml water.
Calorie = 500ml x 1.5kcal/ml x 4 feeding (Ensure Plus)
= 3000kcal/day
Total calorie = 100ml/hr Ensure Plus + 4scoops of Myotein
= 3000kcal + 120.4kcal
=3120.4kcal
Protein = 100g/day + 4 scoops of myotein
= 100g + (4x5g)
= 120g/day
Step 6: 100ml/hr of Ensure Plus (RTU) + Myotein (6 scoops)
Total calorie = 100ml/hr Ensure Plus + 6scoops of Myotein
= 3000kcal + 180.6kcal
=3180.6kcal ~ ACHIEVED!
Protein = 100g/day + 6 scoops of myotein
= 100g + (6x5g)
= 130g/day ~ ACHIEVED!
PEG tube feeding
• After PEG tube was inserted, start fed the patient with lower calorie in order to avoid
any complication after surgery. So, it is suggested to start from step 1 which is similar to
nasogastric tube. If patient can tolerate with 1-2 feeding, proceed to the next
step (step 2, 3,4,5 and 6) until achieved adequate energy requirement.
If patient cannot tolerate with feeding in certain step, back to the previous step.
Implementation
• Education for caregivers
i. Aware the hygiene aspect during preparation of blended diet for patient to avoid any infection occurred.
ii. Encourage caregivers to provide variety of food (blended diet) according to patient’s desire within recommended energy requirement.
iii. Flush the tube with 30ml of water before and after feeding in order to avoid clot.
iv. If caregivers can not afford to buy Ensure Plus, refer to Welfare unit for help.