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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

  • List contraindications to enteral nutrition (EN) therapy.

  • Calculate the protein, calorie, and fluid requirements for a patient who is to receive EN therapy.

  • Recommend an appropriate enteral formula and feeding route.

  • Implement an appropriate monitoring plan to achieve the desired nutritional endpoints and avoid complications.

  • Design an appropriate regimen for administering medications via a feeding tube, including recommending alternate dosage forms for medications that cannot be crushed.

PATIENT PRESENTATION

Paula Ronin is a 60-year-old woman referred to the nutrition support team for evaluation and possible initiation of parenteral nutrition. The history on the referral states: admission to the hospital 2 days ago with c/o nausea, vomiting, and abdominal pain, primarily in the epigastric and LUQ region. Continued c/o nausea and abdominal pain; no vomiting in the last 24 hours. She is NPO except for sips of water for comfort.

QUESTIONS

Collect Information

1. What other information is necessary to evaluate the patient and provide recommendations for a nutrition support plan of care?

CLINICAL COURSE

After following appropriate procedures, you obtain the following additional information about the patient.

HPI

Ms Ronin began having symptoms of nausea and epigastric/LUQ pain about a week (per patient) prior to hospital admission. She thought this would “go away on its own by changing to a high carbohydrate diet; like in the past.” She began feeling weak and dizzy the day before she asked a friend to take her to the ED. She had several episodes of vomiting before going to the ED on the day of admission. Her history indicates five episodes with symptoms of nausea and abdominal pain in the past 6 months. With previous episodes, the pain was reported as less severe and lasted only a couple days; nausea occurred, but there was no vomiting; she tolerated a high-carbohydrate diet and was not weak or dizzy. She did not go to the hospital with the past episodes since the pain improved on its own.

In the ED, Ms Ronin received 6 L of 0.9% NaCl for hydration; D5%/0.45% NaCl + 20 mEq KCl/L has been infusing at 125 mL/hr since then. Imaging in the ED indicated multiple areas of cholelithiasis, potential choledocholithiasis, edema of the proximal pancreatic duct with possible stricture, and a small pancreatic pseudocyst.

Height: 70 in. Weight: no admission weight available; weight on hospital day 2 is 72 kg. Patient states, “I lost about 125 pounds over the past year; I’ve been about 150–155 pounds for the past 3 months and I’m ...

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