Enteral Nutrition: A Clinical Case Study using the Nutrition

Care Process

By Yingying YipFebruary 25, 2015

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

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

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

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.

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

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)

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

Dysphagia

Swallowing difficulty Pain while swallowing, unable to swallow liquids and

foods safely Texture-modified diet and/or thickened liquids

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

CLINICAL CASE STUDY

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

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

PMH

Venous insufficiency, peripheral neuropathy, osteoarthritis, GERD, hyperlipidemia, atrial fibrillation, CAD, DM, osteoporosis, HTN, BPH

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

Nutrition Assessment - Physical Exam

Alert and oriented x3 Skin warm and dry Abdomen soft

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

Nutrition Assessment – Anthropometric measurement

Height: 69 in / 175 cm Weight: 188.5 lbs / 85.7 kg BMI: 28 IBW: 172 lbs / 78.2 kg

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

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

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  

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

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:

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

Nutrition Diagnosis - PES

Inadequate oral intake related to swallowing dysfunction as evidenced by poor PO intake PTA and patient NPO

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

Nutrition Monitoring and Evaluation

Indicator: Enteral nutrition Criteria: tolerate bolus feed at goal

Indicator: Electrolytes and renal profile Criteria: WNL

NUTRITION FOLLOW-UPS

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

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

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

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

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

Lessons

Diabetes-specific enteral formula Tube feeding complications Continuous tube feed vs Bolus feed

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

Thank You!

Any Questions?

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

Complications

Diarrhea/constipation/nausea/vomiting Distention/bloating/cramping Aspiration Dehydration/overhydration Malabsorption/maldigestion Hyperglycemia Refeeding syndrome