1. MEDICAL NUTRITION THERAPY
CASE STUDY 1
GROUP MEMBERS:
NURNAIMAH MD KASSIM
NUR KHAIRUNNISA JALALUDIN
FATIMAH AMIRAH ZAKARIA
NOR FAIZAH MUSTAFA

2. RK is a 25 years old man, who was involved in MVA. He
had multiple fractures, contusions, and severe head injury.
He was unconscious most of the time and being fed via
nasogastric tube feeding. RK’s lab results were normal upon
admission with exception of Hb (8.1 g/dL) and Hematocrit
(31%). His height is 179 cm and weight is 80 kg, and he
loss about 5 kg within 3 weeks of ICU stay. Currently he
was on Ensure plus 50cc/Hr and physician is planning to
insert PEG tube. Discuss the dietary care plan for RK’s
current condition and after PEG tube was inserted.
Case Study 1

3. PEG = Percutaneous
Endoscopic Gastrostomy

4. • Subjective Data
 Name : RK
 Age : 25 years old
 Involved in MVA, had multiple fractures, contusions and
severe head injury.
Assessment

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. Weight loss related to inadequate calorie intake as evidence
by loss 5kg within 3 weeks of ICU stay.
PES Statement

7. OBJECTIVES PRINCIPLES
• Calculate the estimated
energy requirement by
considering his condition
1) 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. OBJECTIVES PRINCIPLES
2) To provide nutrition • To monitor either the patient
support consistent with the can tolerate the enteral
feeding via PEG tube.
patient’s nutritional status
• To manage the enteral
and available route of feeding of the patient from
nutrient administration. small amount of calorie
intake after insertion of
PEG tube due to post
surgery condition.

9. OBJECTIVE PRINCIPLE
• To provide the sufficient
3) To maintain current body energy requirement base
weight. on his condition.
• To avoid lack or over
feeding for the patient.

10. OBJECTIVE PRINCIPLE
4) To avoid and manage • To educate the caregiver
complications or infection of the patient on the
related to the technique of proper management and
nutritional 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. OBJECTIVE PRINCIPLE
• To provide adequate
5) To improve patient’s nutrient like
condition 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. • 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/day
Calculation of Energy
Requirement

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
9
Macronutrients Distribution.

14. Ensure plus Composition
Energy 1.5kcal/ml
CHO 0.2g/ml
Protein 0.05g/ml
Fat 0.05g/ml
Calcium 0.8g/ml
Phosphorus 0.8g/ml
Magnesium 0.4g/ml
Ensure plus (RTU)

15. Ensure Plus (RTU)
Step 1: 50ml/hour of Ensure Plus (RTU) (5hours+1hour
rest)
Calorie = 250ml/5hrs x 1.5kcal/ml x 4feeding
= 1500kcal/day
Protein = 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. Step 2: 70ml/hour of Ensure Plus (RTU) (5hours+1hour
rest)
Calorie = 350ml/5hrs x 1.5kcal/ml x 4feeding
= 2100kcal/day
Protein = 1400ml x 0.05g/ml
= 70g/day
If patient can tolerate 1-2 feeding, go to step 3.
Before and after feeding flush with 30ml water.

17. Step 3: 90ml/hour of Ensure Plus (RTU) (5hours+1hour
rest)
Calorie = 450ml/5hours x 1.5kcal/ml x 4 feeding
= 2700kcal/day
Protein = 1800ml x 0.05g/ml
= 90g/day
If patient can tolerate 1-2 feeding, go to step 4.
Before and after feeding flush with 30ml water.

18. Step 4: 100ml/hour of Ensure Plus (RTU)
(5hours+1hour rest)
Calorie = 500ml x 1.5kcal/ml x 4 feeding
= 3000kcal/day
Protein = 2000ml x 0.05g/ml
= 100g/day
If patient can tolerate 1-2 feeding, go to step 5.
Before and after feeding flush with 30ml water.

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 time
don’t want to add more calorie to the patient’s feeding.
Myotein Composition
Energy 30.1kcal/scoop
Protein 1scoop = 5g

20. Calorie = 500ml x 1.5kcal/ml x 4 feeding (Ensure Plus)
= 3000kcal/day
Total calorie = 100ml/hr Ensure Plus + 4scoops of Myotein
= 3000kcal + 120.4kcal
=3120.4kcal
Protein = 100g/day + 4 scoops of myotein
= 100g + (4x5g)
= 120g/day
If patient can tolerate 1-2 feeding, go to step 6.
Before and after feeding flush with 30ml water.

21. Step 6: 100ml/hr of Ensure Plus (RTU) + Myotein (6
scoops)
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. • 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. • Education for caregivers
i. 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