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  2. 2. RK is a 25 years old man, who was involved in MVA. Hehad multiple fractures, contusions, and severe head injury.He was unconscious most of the time and being fed vianasogastric tube feeding. RK’s lab results were normal uponadmission with exception of Hb (8.1 g/dL) and Hematocrit(31%). His height is 179 cm and weight is 80 kg, and heloss about 5 kg within 3 weeks of ICU stay. Currently hewas on Ensure plus 50cc/Hr and physician is planning toinsert PEG tube. Discuss the dietary care plan for RK’scurrent condition and after PEG tube was inserted.Case Study 1
  3. 3. PEG = PercutaneousEndoscopic Gastrostomy
  4. 4. • Subjective Data Name : RK Age : 25 years old Involved in MVA, had multiple fractures, contusions and severe head injury. Assessment
  5. 5. • Objective Data Height : 179cm Weight :80kg (loss 5kg within 3 weeks during ICU stay) BMI : 25kg/m² DietaryBeing fed via nasogastric tube feeding (continuous feeding)Currently on Ensure Plus 50cc/hr Biochemical data Data Result Normal Indication range Hemoglobin 8.1g/Dl 14-17g/dL Low ( loss many blood due to MVA) Hematocrit 31% normal adult Low ( loss many blood due to male range MVA) 41-53%)
  6. 6. Weight loss related to inadequate calorie intake as evidence by loss 5kg within 3 weeks of ICU stay.PES Statement
  7. 7. OBJECTIVES PRINCIPLES • Calculate the estimated energy requirement by considering his condition1) To ensure adequate energy (on bed, unconscious, low blood count and bone requirement meet. fractures). • Provide energy intake gradually (step by step until patient meet the adequate energy requirement). Objectives & Principles
  8. 8. OBJECTIVES PRINCIPLES2) To provide nutrition • To monitor either the patientsupport consistent with the can tolerate the enteral feeding via PEG tube.patient’s nutritional status • To manage the enteraland available route of feeding of the patient fromnutrient administration. small amount of calorie intake after insertion of PEG tube due to post surgery condition.
  9. 9. OBJECTIVE PRINCIPLE • To provide the sufficient3) To maintain current body energy requirement baseweight. on his condition. • To avoid lack or over feeding for the patient.
  10. 10. OBJECTIVE PRINCIPLE4) To avoid and manage • To educate the caregivercomplications or infection of the patient on therelated to the technique of proper management andnutritional delivery. 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.
  11. 11. OBJECTIVE PRINCIPLE • To provide adequate5) To improve patient’s nutrient likecondition on low blood protein(0.05g/ml),count and bone fractures. calcium(0.8g/ml) , magnesium(0.4g/ml) and phosphorus(0.8g/ml) to improve the patient recovery.
  12. 12. • Current BMI = 25kg/m² (overweight)• Energy requirement • Protein intake Harris-Benedict Equation: 80kg x 1.6 (head 66+(13.7xWt)+(5xHt)-(6.8xA) injury) 66+(13.7x80)+(5x179)-(6.8x25) = 128g/day =1887kcal TEE=BEE x AF( confined to bed) x IF (head injury) 1887x1.2x1.4 3170.16kcal/day ≈ 3100kcal/dayCalculation of EnergyRequirement
  13. 13. • 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 9Macronutrients Distribution.
  14. 14. Ensure plus CompositionEnergy 1.5kcal/mlCHO 0.2g/mlProtein 0.05g/mlFat 0.05g/mlCalcium 0.8g/mlPhosphorus 0.8g/mlMagnesium 0.4g/ml Ensure plus (RTU)
  15. 15. Ensure Plus (RTU)Step 1: 50ml/hour of Ensure Plus (RTU) (5hours+1hourrest)Calorie = 250ml/5hrs x 1.5kcal/ml x 4feeding = 1500kcal/dayProtein = 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.
  16. 16. Step 2: 70ml/hour of Ensure Plus (RTU) (5hours+1hourrest)Calorie = 350ml/5hrs x 1.5kcal/ml x 4feeding = 2100kcal/dayProtein = 1400ml x 0.05g/ml = 70g/dayIf patient can tolerate 1-2 feeding, go to step 3.Before and after feeding flush with 30ml water.
  17. 17. Step 3: 90ml/hour of Ensure Plus (RTU) (5hours+1hourrest)Calorie = 450ml/5hours x 1.5kcal/ml x 4 feeding = 2700kcal/dayProtein = 1800ml x 0.05g/ml = 90g/dayIf patient can tolerate 1-2 feeding, go to step 4.Before and after feeding flush with 30ml water.
  18. 18. Step 4: 100ml/hour of Ensure Plus (RTU)(5hours+1hour rest)Calorie = 500ml x 1.5kcal/ml x 4 feeding = 3000kcal/dayProtein = 2000ml x 0.05g/ml = 100g/dayIf patient can tolerate 1-2 feeding, go to step 5.Before and after feeding flush with 30ml water.
  19. 19. 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 timedon’t want to add more calorie to the patient’s feeding. Myotein Composition Energy 30.1kcal/scoop Protein 1scoop = 5g
  20. 20. Calorie = 500ml x 1.5kcal/ml x 4 feeding (Ensure Plus) = 3000kcal/dayTotal calorie = 100ml/hr Ensure Plus + 4scoops of Myotein = 3000kcal + 120.4kcal =3120.4kcalProtein = 100g/day + 4 scoops of myotein = 100g + (4x5g) = 120g/dayIf patient can tolerate 1-2 feeding, go to step 6.Before and after feeding flush with 30ml water.
  21. 21. Step 6: 100ml/hr of Ensure Plus (RTU) + Myotein (6scoops)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!
  22. 22. • 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.PEG tube feeding
  23. 23. • Education for caregiversi. 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.Implementation