Enteral Nutrition: A Clinical Case Study using the Nutrition Care Process

1. Enteral Nutrition: A Clinical Case Study using the Nutrition Care Process By Yingying Yip February 25, 2015

2. 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

3. 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

4. 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

5. 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.

6. 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

7. 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)

8. 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

9. Dysphagia • Swallowing difficulty • Pain while swallowing, unable to swallow liquids and foods safely • Texture-modified diet and/or thickened liquids

10. Aspiration • Acondition 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

11. Clinical Case Study

12. 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

13. 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

14. PMH • Venous insufficiency, peripheral neuropathy, osteoarthritis, GERD, hyperlipidemia, atrial fibrillation, CAD, DM, osteoporosis, HTN, BPH

15. 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

16. Nutrition Assessment - Physical Exam • Alert and oriented x3 • Skin warm and dry • Abdomen soft

17. 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

18. Nutrition Assessment – Anthropometric measurement • Height: 69 in / 175 cm • Weight:188.5 lbs/ 85.7 kg • BMI:28 • IBW:172 lbs / 78.2 kg

19. 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

20. Nutrition Assessment – Biochemical Data

21. Nutrition Assessment – Biochemical Data

22. Medications

23. Medications Prescribed during this hospital stay:

24. 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

25. Nutrition Diagnosis - PES • Inadequate oral intake related to swallowing dysfunction as evidenced by poor PO intake PTA and patient NPO

26. 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

27. Nutrition Monitoring and Evaluation • Indicator: Enteral nutrition • Criteria: tolerate bolus feed at goal • Indicator: Electrolytes and renal profile • Criteria: WNL

28. Nutrition Follow-ups

29. Nutrition Follow-up #1 • JB w/ pleural effusion. Had diarrhea after each feed, refused feeding that morning. Formula changed to Osmolite1.2. 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

30. Formulas used in this case study

31. Nutrition Follow-up #2 • 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

32. 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

33. 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

34. Lessons • Diabetes-specific enteral formula • Tube feeding complications • Continuous tube feed vs Bolus feed

35. 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

36. Thank You! Any Questions?

37. 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

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