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# CASE STUDY 1 (Q2)

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### CASE STUDY 1 (Q2)

1. 1. 0913252 • NORASHIKIN MUSTAFA0917992 • MARIAM NABILAH0910592 • WAN NURUL HAZIRAH0913838 • NUR AFIFAH’ AMALINA0914606 • WAN NOR AMALINA
2. 2. Question 2AH is a 82 years old man. He had been diagnosed with cancer last yearand had finished all the radiation therapy all together 15 treatments. Butrecently patient had admitted back to hospital due to pyloric cancer andunderwent operation of the stomach. Currently he is on TPN, and thephysician 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 onthe next day.Discuss the dietary care plan for AH in current condition and after changingto 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/LnormalTotal Protein: 59 g/L Albumin: 29 g/dL
3. 3. OVERVIEW Name = AH Sex = Male Age = 82 years old Condition = 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 Q: condition + after changing to EN solely?
4. 4. Anthropometry DataWeight = 42 kgHeight = 165 cmBMI = 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
5. 5. BIOCHEMMICAL ASSESTMENTCHEMICAL INDICATION ASSESTMENT Malnutrition due to previous RBG Low cancer condition Hb Low Due to cancer condition PEM due to previous cancer condition T.Prot Low Electrolite imbalance due to fasting procedure before the Na Slightly Low surgical : PEM due to previous cancer Albumin Low condition
6. 6. 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 DAY 3 DAY 7 • TPN – • Total EN Nutriflex • Mix PN + • Total EN (75 ml/hr) EN (based on IBW) DAY 1 +2 DAY 4-6
7. 7. PES STATEMENTMalnutrition due to previous cancercondition as evidenced by low albuminlevel which is 29g/dL in biochemicalassessment.
8. 8. Objectives of MNT1. 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.
9. 9. 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.
10. 10. 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.
11. 11. Implementation 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.
12. 12. ENERGY & PROTEIN REQUIREMENTFAO/WHO/UNU Formula BEE > 60 (male) = 13.5(W)+ 487BEE = 13.5( 42) + 487 = 1054kcalTEE = 1054 X AF (1.0) X IF (1.3) =1370 kcal/daySchofield Equation BEE > 60 (male)= 11.7(W)+585BEE = 11.7 (42) + 585 = 1076.4kcalTEE = 1076.4 + SF (0.2 X 1076.4) + AF ( 0.1 X 1076.4) = 1399.32 kcal/day Adjusted for 24 hr Stress factor energy expenditure (extensive surgery) (bed bound and = 10-30% awake)= +10%
13. 13. ENERGY & PROTEIN REQUIREMENTAverage E= (1370 + 1399.32)/2 = 1384.66 ≈ 1300 - 1400kcal/dayProtein = 1.2 g-1.5 g/BW = 50.4g – 63 g/day
14. 14. DAY 1 & 2 (TPN) Nutriflex (75ml/hr) = 1875 ml/1435 kcal/ 60g a.aml/cc in 1 day = 75 ml/hr x 24 hr = 1800 ml NuTRIflex Lipid PeriCal in 1 day = (1435 kcal/1875 ml) x 1800 ml (peripheral) = 1377.6 kcal / dayProtein. in 1 day = (60 g/1875 ml) x 1800 ml = 57.6 g protein/day = 1.37 g/kg BWGlucose in 1 day = (120g/1875ml) x 1800ml(CHO) = 115.2g CHO/dayLipids in 1 day = (75g/1875ml) x 1800ml(Fat) = 72g Fat/day
15. 15. DAY 3 ( PN + EN)PNNutriflex = 1250 ml/ 955kcal/ 40g a.aEN 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
16. 16. Peptamen = 42 kcal/ 1.7g protein/ 35 ml water/ scoopBolus feeding (6 times /day)1. Flush with 30 ml water2. Give clear fluid like water 40ml.3. 1 ½ scoop + (70 ml water) = 1 ½ scoop x 42 kcal = 63 kcal/feeding time Total Calories = 63 kcal x 6 feeding = 378 kcal/day Total 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/day3. Flush with 30 ml water
17. 17. DAY 3 ( PN + EN)Average energy requirement ≈ 1300 - 1400kcal/dayProtein = 1.2 g-1.5 g/BW = 50.4g – 63 g/dayTotal calorie (PN+EN) = 955kcal + 378kcal = 1333 kcalTotal protein (PN+EN)= 40g +15.3 g = 55.3g
18. 18. DAY 4-6 ( TEN ) Peptamen = 42 kcal/ 1.7g protein/ 35 ml water/ scoopSTEP 11. Flush with 30 ml water1.(4 scoop + 140 ml water) x 6 feeding Total Calories = 4 (42kcal) x 6= 1008 kcal/day Total Protein = 4(1.7g) x 6 = 40.8 g/day Total CHO = 4(5.1g) = 20.4g/day Total Fat =4(1.6g) = 6.4g/day3. Flush with 30 ml water
19. 19. DAY 4-6 ( TEN ) Peptamen = 42 kcal/ 1.7g protein/ 35 ml water/ scoopSTEP 21. Flush with 30 ml water1.(5 scoop + 175 ml water) x 6 feeding Add 1 scoop (6.3g) myotein in 2 times feeding per day Calories = 5(42kcal) x 6 + 2(30.1) = 1320.2 kcal/day Protein = 5(1.7g) x 6 + 2(5g) = 61 g/day Total CHO = 5(5.1g) x 6 = 153g/day Total fat = 5(1.6g) x 6 = 48g/ day3. Flush with 30 ml water
20. 20. 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/daySchofield EquationBEE =11.7 (50) + 585 (for >60 y.o) = 1170kcalTEE = 1170 + SF (0.2 X 1170) + AF ( 0.1 X 1170) = 1521 kcal/dayAverage = (1510.6+ 1521)/2 =1515.8 kcal (1500- 1600 kcal)Protein = 1.2 – 1.5 g/kg BW = 60 – 75g/day
21. 21. DAY ≥ 7 (TEN based IBW)STEP 31. Flush with 30ml of water2. (6 scoop + 210 ml water) x 6 feeding Calories =6 (42kcal) x 6= 1512 kcal/day Total Protein =6(1.7g) x 6 = 61.2 g/day Total CHO =6 (5.1g) x 6 = 183.6g/day Total fat = 6(1.6g) x 6 = 57.6g/day3. Flush with 30 ml water
22. 22. ~The End~ ~Thank You~