Discuss the strengths and limitations associated with various enteral feeding routes by completing the table below (10 points):

You can make this table bigger or add more boxes if you need to in order to complete it:
Describe the various administration methods available for infusing enteral nutrition including which methods can be used based on where the feeding tube is positioned (5 points).

A 55 y.o. male lives with his wife in an apartment in a large metropolitan city and has an appointment with you today because he “feels like” he is not tolerating his PEG feedings. He has a PEG in place due to severe dysphagia related to a neurologic disorder. The PEG was placed last month and he had been doing “fine” on his feedings until last week.

Ht: 6’ Current Wt: 166 lbs. (weight changed occurred in the past 3 weeks)
Weight 4 months ago: 172 lbs. (stable)
Labs: WNL

Physical activity: none as he is wheel chair bound

Challenges with PEG feeding: he reports that he infuses 2 cans of Osmolite at 8 am and 2 cans at 10 am (1.06 kcal/mL, 10 gms protein/can and 84% free water) and 1 can at 3 pm but he is too full to infuse any more for the rest of the day. He flushes his feeding tube before and after each infusion with 60 mL water. He also flushes the feeding tube in between feedings three times per day with 120 mL of water.

Calculate energy, pro, fluid the above regimen is providing. Is the EN provided meeting this patient’s needs? What % of energy, pro and fluid are being met? Is the EN volume meeting micronutrient needs? (5 pts)

Complete a nutrition assessment (10 points):

Design 1 PES statement (3 points):
P:
E:
S:

Nutrition Prescription (4 points):
Kcals:
Grams of protein:
Fluid requirements:
How will micronutrient needs be met:

Provide your specific recommendations, including whether you would recommend changing what he is currently doing, and how this patient can meet his estimated nutrient and hydration needs with his PEG feedings; be specific in terms of formula to use, infusion method and amount, and address meeting free water needs (10 points):
Case Study:
TB is a 57 year-old female who was recently diagnosed with stage IIB esophageal adenocarcinoma in her lower esophagus. She recently completed radiation and chemotherapy for treatment. She has been admitted to the hospital now for surgical treatment – removal of any remaining tumor. Today is hospital day #2. TB underwent surgical resection of the lower esophagus with the upper esophagus anastomosed to the upper stomach yesterday. The gastroesophageal sphincter was removed along with a small portion of the upper stomach and lower esophagus (see illustration). She is currently stable, intubated and sedated in the surgical ICU. She had a feeding jejunostomy placed in surgery. She has no bowel sounds and has not passed any stool. Her nasogastric tube is putting out 1.2 liters at this time. I.V. fluids via a PICC line running at 100 mL/hr with normal saline & D5W with 20 mEq of KCl. A nutrition consult is requested.

Patient History:
Height: 5’9” Current Weight: 147 lbs. Weight 5 months ago: 175 lbs.
Labs: Sodium: 135 (135-145) Potassium: 3.8 (3.5-5.5) Chloride: 103 (99-112)
Bicarb: 26 (22-29) Fasting glucose: 89 (65-99) BUN: 11 (8-24) Creatinine: 0.7 (0.6-1.1)
Albumin: 2.9 (3.5-5.5) WBC: 13 (4-11) Hemoglobin: 13 (11-15.8)
Mg: 1.7 (1.5-2.5) Phosphorus: 2.7 (2.5-4.5)

Vitals: Blood pressure: 130/80 Mean arterial pressure: 66, 65, 67 Temperature: 99°
Meds: IV antibiotic, pantoprazole, and pain meds
Past medical history: breast cancer 10 years ago, gastroesophageal reflux disease and hypertension
Nutrition-focused physical exam: acromion process slightly protruding; depth pinch of triceps/biceps region not ample; some protrusion of clavicle; ribs apparent; and mild depression of inner thigh

Social history: retired attorney; married to CB and has 2 adult children
Nutrition history:
• Walked 2 miles per day prior to hospitalization
• Breakfast: 2 scrambled egg whites with 1 oz of cheese and ½ c spinach w/chopped tomatoes. 1 piece of whole wheat toast w/smear of butter and jelly. 4 oz. orange juice and hot tea (8 oz.)
• Lunch: soup – either chicken noodle or vegetable with ½ of sandwich (either chicken, tuna or egg salad – about a 1/3 of a cup). Small piece of fruit (apple, pear, plum or orange). Hot tea (8 oz.)
• Snack: 1 ounce of cheddar cheese with 2 triscuits OR some grapes and 10 almonds; hot tea
• Dinner: 3 oz. of meat, chicken or fish with some type of starch (pasta, rice, or sweet potato – about ½ cup), mixed salad (with greens, carrots, onion, broccoli (all together ~1/2 c) and cran-raisins (1 tsp.)) with 1 Tbsp. fat-free dressing and cooks veggies (~1/2 c). hot tea (10 oz.)
• Evening snack: ½ c Ben & Jerry’s ice cream OR popsicle OR small chocolate brownie – usually the popsicle

Complete a nutrition assessment (10 points):