CASE STUDIES 1 : Q 2
• NORASHIKIN MUSTAFA0913252
• MARIAM NABILAH 0917992
• WAN NURUL HAZIRAH 0910592
0913838
0914606
• NUR AFIFAH’ AMALINA
• WAN NOR AMALINA
Question 2AH is a 82 years old man. He had been diagnosed with cancer last year and had finished all the radiation therapy all together 15 treatments. But recently patient had admitted back to hospital due to pyloric cancer and underwent operation of the stomach. Currently he is on TPN, and the physician already done gastrojejunostomy for long term plan.He is on Nutriflex (peripheral) after operation (75 ml/hr). After 2 days, he started with mix feeding TPN and EN, before changing to EN solely on the next day. Discuss the dietary care plan for AH in current condition and after changing to EN solely.Anthropometry Data: Weight = 42 kg; Height = 165cmBiochemical Data:RBG: 6.2 mmol/L Hb: 10.1 g/dLUrea: 5.9 mmol/L Potassium: 4.5 mmol/LSodium:134 mmol/L Creatinine: 94 mmol/L normalTotal Protein: 59 g/L Albumin: 29 g/dL
OVERVIEWName = AHSex = MaleAge = 82 years oldCondition = PYLORIC CANCER +
done GASTROJEJUNOSTOMY + on TPN, Nutriflex (peripheral) after
operation (75ml/hr).After 2 days = TPN + EN before EN solely.
•Discuss the dietary care plan in current condition + after changing to EN solely?Q:
Anthropometry Data
Weight = 42 kgHeight = 165 cmBMI = 15.43 kg/m² (underweight)IBW = 50 kg @ normal BMI 18.5 kg/m²Biochemical Data
:
CHEMICAL VALUE N.VALUE INDICATION
RBG 6.2 mmol/L 7- 11 mmol/L Low
Hb 10.1 g/dL 12.1-15.1 g/dL Low
Urea 5.9 mmol/L 2.0-6.8 mmol/L Normal
K 4.5 mmol/L 3.5-5.5 mmol/L Normal
Na 134 mmol/L 135-145 mmol/L Slightly Low
Creatinine 94 mmol/L 60-110 mmol/L Normal
T.Prot 59 g/L 68-83 g/L Low
Albumin 29 g/dL 35-40 g/dL Low
:
BIOCHEMMICAL ASSESTMENT
CHEMICAL INDICATION ASSESTMENT
RBG LowMalnutrition due to previous
cancer condition
Hb Low Due to cancer condition
T.Prot Low
PEM due to previous cancer condition
Na Slightly Low
Electrolite imbalance due to fasting procedure before the
surgical
Albumin LowPEM due to previous cancer
condition
Clinical Data Diagnosed with cancer and had finished all the 15 radiation
therapies. Recently, admitted back due to pyloric cancer and underwent
operation of the stomach Gastrojejunostomy for long term EN plan.
Dietary Plan
• TPN –Nutriflex (75 ml/hr)
DAY 1 +2
• Mix PN + EN
DAY 3 • Total EN
DAY 4-6
• Total EN (based on IBW)
DAY 7
PES STATEMENT
Malnutrition due to previous cancer condition as evidenced by low albumin level which is 29g/dL in biochemical assessment.
Objectives of MNT
1. To provide nutrition support consistent with patient’s medical condition, nutritional status, and available route of administration.
2. To improve patient’s nutritional status and outcomes after surgery.
3. To avoid complications related to the technique of nutritional delivery.
Implementation
To provide nutrition support consistent with patient’s medical condition, nutritional status, and available route of administration.
1) The process of changing nutrition support from TPN to mix feeding of PN and EN, until total EN is accomplished through gradual stage to avoid refeeding syndrome and to parallel with patient’s condition.
Post surgery, patient is given TPN (Nutriflex) for 2 days considering that patient is underwent surgery for pyloric cancer.
Then, patient is given mix feeding of PN and EN before TEN is given to patient, but the amount of feeding is increase gradually to avoid re-feeding syndrome.
2) The product selected for EN of this patient is Peptamen®. It is an elemental formula which is nutritionally complete and suitable for post operative patients. It is also a partially hydrolyzed protein product that is easily absorbed by the GIT.
Implementation
To improve patient’s nutritional status and outcomes after surgery.
i. The initial estimation of nutrient requirements is based on current body weight (1300-1400 kcal/day) to promote adequate energy intake but preventing the refeeding syndrome.
ii. After 7 days, the ideal body weight is used to estimate the energy requirement to promote weight gain (1500-1600 kcal/day)
iii. Higher protein factor of 1.2-1.5g/kg BW is used to calculate protein requirement for this post surgery patient in order to promote wound healing and tissue repair as well as improving protein stores.
To avoid complications related to the technique of nutritional delivery.
i. The tube is flush with 30ml of water before and after feeding to prevent occlusion.
ii. Elevate the head of the bed 30-45 degrees during feeding and 30-60 minutes after feedings to minimize the risk of aspiration.
iii. Practice hygiene through the whole process of feeding the patient including preparing the enteral formula, feedings, and also post-feeding cleanliness to prevent bacterial contamination.
Implementation
ENERGY & PROTEIN REQUIREMENTFAO/WHO/UNU FormulaBEE = 13.5( 42) + 487 = 1054kcalTEE = 1054 X AF (1.0) X IF (1.3) =1370 kcal/day
Schofield EquationBEE = 11.7 (42) + 585 = 1076.4kcalTEE = 1076.4 + SF (0.2 X 1076.4) + AF ( 0.1 X 1076.4)
= 1399.32 kcal/day
BEE > 60 (male) = 13.5(W)+ 487
BEE > 60 (male)= 11.7(W)+585
Stress factor (extensive surgery)
= 10-30%
Adjusted for 24 hr energy expenditure
(bed bound and awake)= +10%
Average E= (1370 + 1399.32)/2 = 1384.66 ≈ 1300 - 1400kcal/day
Protein = 1.2 g-1.5 g/BW = 50.4g – 63 g/day
ENERGY & PROTEIN REQUIREMENT
DAY 1 & 2 (TPN)Nutriflex (75ml/hr) = 1875 ml/1435 kcal/ 60g a.a
ml/cc in 1 day = 75 ml/hr x 24 hr = 1800 ml
Cal in 1 day = (1435 kcal/1875 ml) x 1800 ml = 1377.6 kcal / day
Protein. in 1 day = (60 g/1875 ml) x 1800 ml = 57.6 g protein/day = 1.37 g/kg BW
Glucose in 1 day = (120g/1875ml) x 1800ml(CHO) = 115.2g CHO/dayLipids in 1 day = (75g/1875ml) x 1800ml(Fat) = 72g Fat/day
NuTRIflex Lipid Peri
(peripheral)
DAY 3 ( PN + EN)
PNNutriflex = 1250 ml/ 955kcal/ 40g a.a
EN Cal for EN = 1377.6 kcal – 955 kcal
= 422.6 kcal/day (400-500kcal/day) Min Protein from EN =57.6 g – 40 g = 17.6 g
Peptamen = 42 kcal/ 1.7g protein/ 35 ml water/ scoop
Bolus feeding (6 times /day)1.Flush with 30 ml water
2.Give clear fluid like water 40ml.
3.1 ½ scoop + (70 ml water) = 1 ½ scoop x 42 kcal = 63 kcal/feeding timeTotal Calories = 63 kcal x 6 feeding = 378 kcal/dayTotal Protein = 1.7 g x 1 ½ scoop x 6 feeding= 15.3 g/day Total CHO = 5.1g x 1 ½ scoop x 6 feeding = 45.9g/day
Total fat =1.6g x 1 ½ scoop x 6 feeding = 14.4g/day
3.Flush with 30 ml water
Average energy requirement ≈ 1300 - 1400kcal/dayProtein = 1.2 g-1.5 g/BW = 50.4g – 63 g/day
Total calorie (PN+EN) = 955kcal + 378kcal = 1333 kcal
Total protein (PN+EN)= 40g +15.3 g = 55.3g
DAY 3 ( PN + EN)
DAY 4-6 ( TEN ) Peptamen = 42 kcal/ 1.7g protein/ 35 ml water/ scoop
STEP 1
1. Flush with 30 ml water
2.(4 scoop + 140 ml water) x 6 feeding Total Calories = 4 (42kcal) x 6= 1008 kcal/dayTotal Protein = 4(1.7g) x 6 = 40.8 g/dayTotal CHO = 4(5.1g) = 20.4g/dayTotal Fat =4(1.6g) = 6.4g/day
3. Flush with 30 ml water
DAY 4-6 ( TEN )
Peptamen = 42 kcal/ 1.7g protein/ 35 ml water/ scoopSTEP 21. Flush with 30 ml water
2.(5 scoop + 175 ml water) x 6 feeding
Add 1 scoop (6.3g) myotein in 2 times feeding per dayCalories = 5(42kcal) x 6 + 2(30.1) = 1320.2 kcal/dayProtein = 5(1.7g) x 6 + 2(5g) = 61 g/day Total CHO = 5(5.1g) x 6 = 153g/dayTotal fat = 5(1.6g) x 6 = 48g/ day
3. Flush with 30 ml water
DAY ≥ 7 (TEN based IBW)
FAO/WHO/UNU FormulaBEE = 13.5( 50) + 487 = 1162 kcalTEE = 1054 X AF (1.0) X IF (1.3) =1510.6 kcal/day
Schofield EquationBEE =11.7 (50) + 585 (for >60 y.o) = 1170kcalTEE = 1170 + SF (0.2 X 1170) + AF ( 0.1 X 1170)
= 1521 kcal/day
Average = (1510.6+ 1521)/2=1515.8 kcal (1500- 1600 kcal)
Protein = 1.2 – 1.5 g/kg BW= 60 – 75g/day
DAY ≥ 7 (TEN based IBW) STEP 3
1. Flush with 30ml of water2. (6 scoop + 210 ml water) x 6 feeding
Calories =6 (42kcal) x 6= 1512 kcal/dayTotal Protein =6(1.7g) x 6 = 61.2 g/dayTotal CHO =6 (5.1g) x 6 = 183.6g/dayTotal fat = 6(1.6g) x 6 = 57.6g/day
3. Flush with 30 ml water
~The End~~Thank
You~
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