0913252 • NORASHIKIN MUSTAFA

0917992 • MARIAM NABILAH

0910592 • WAN NURUL HAZIRAH

0913838 • NUR AFIFAH’ AMALINA

0914606 • WAN NOR AMALINA

 Question 2
AH is a 82 years old man. He had been diagnosed with cancer last year
and had finished all the radiation therapy all together 15 treatments. But
recently patient had admitted back to hospital due to pyloric cancer and
underwent operation of the stomach. Currently he is on TPN, and the
physician 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 on
the next day.
Discuss the dietary care plan for AH in current condition and after changing
to EN solely.
Anthropometry Data: Weight = 42 kg; Height = 165cm
Biochemical Data:
RBG: 6.2 mmol/L Hb: 10.1 g/dL
Urea: 5.9 mmol/L Potassium: 4.5 mmol/L
Sodium: 134 mmol/L Creatinine: 94 mmol/L
normal
Total Protein: 59 g/L Albumin: 29 g/dL
 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?
Anthropometry Data

Weight = 42 kg
Height = 165 cm
BMI = 15.43 kg/m² (underweight)
IBW = 50 kg @ normal BMI 18.5 kg/m²
Biochemical 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
BIOCHEMMICAL ASSESTMENT

CHEMICAL 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
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
 PES STATEMENT
Malnutrition due to previous cancer
condition as evidenced by low albumin
level which is 29g/dL in biochemical
assessment.
 Objectives of MNT

1. 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.
 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.
 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.
 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.
 ENERGY & PROTEIN REQUIREMENT
FAO/WHO/UNU Formula
BEE > 60 (male) = 13.5(W)+ 487
BEE = 13.5( 42) + 487
= 1054kcal
TEE = 1054 X AF (1.0) X IF (1.3) =1370 kcal/day

Schofield Equation
BEE > 60 (male)= 11.7(W)+585
BEE = 11.7 (42) + 585
= 1076.4kcal
TEE = 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%
ENERGY & PROTEIN REQUIREMENT

Average E= (1370 + 1399.32)/2 = 1384.66 ≈ 1300 - 1400kcal/day

Protein = 1.2 g-1.5 g/BW = 50.4g – 63 g/day

 DAY 1 & 2 (TPN)
Nutriflex (75ml/hr) = 1875 ml/1435 kcal/ 60g a.a

ml/cc in 1 day = 75 ml/hr x 24 hr

= 1800 ml NuTRIflex Lipid
Peri
Cal in 1 day = (1435 kcal/1875 ml) x 1800 ml (peripheral)
= 1377.6 kcal / day
Protein. in 1 day = (60 g/1875 ml) x 1800 ml
= 57.6 g protein/day
= 1.37 g/kg BW
Glucose in 1 day = (120g/1875ml) x 1800ml
(CHO) = 115.2g CHO/day
Lipids in 1 day = (75g/1875ml) x 1800ml
(Fat) = 72g Fat/day
 DAY 3 ( PN + EN)

PN
Nutriflex = 1250 ml/ 955kcal/ 40g a.a

EN
 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
 Peptamen = 42 kcal/ 1.7g protein/ 35 ml water/ scoop

Bolus feeding (6 times /day)

1. Flush with 30 ml water
2. 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/day
3. Flush with 30 ml water
 DAY 3 ( PN + EN)

Average energy requirement ≈ 1300 - 1400kcal/day

Protein = 1.2 g-1.5 g/BW = 50.4g – 63 g/day

Total calorie (PN+EN) = 955kcal + 378kcal

= 1333 kcal

Total protein (PN+EN)= 40g +15.3 g

= 55.3g
 DAY 4-6 ( TEN )
Peptamen = 42 kcal/ 1.7g protein/ 35 ml water/ scoop
STEP 1

1. Flush with 30 ml water

1.(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/day

3. Flush with 30 ml water

 DAY 4-6 ( TEN )
Peptamen = 42 kcal/ 1.7g protein/ 35 ml water/ scoop
STEP 2
1. Flush with 30 ml water

1.(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/ day

3. Flush with 30 ml water

 DAY ≥ 7 (TEN based IBW)
FAO/WHO/UNU Formula
BEE = 13.5( 50) + 487 = 1162 kcal
TEE = 1054 X AF (1.0) X IF (1.3) =1510.6 kcal/day

Schofield Equation
BEE =11.7 (50) + 585 (for >60 y.o) = 1170kcal
TEE = 1170 + SF (0.2 X 1170) + AF ( 0.1 X 1170)
= 1521 kcal/day

Average = (1510.6+ 1521)/2

=1515.8 kcal (1500- 1600 kcal)

Protein = 1.2 – 1.5 g/kg BW

= 60 – 75g/day
 DAY ≥ 7 (TEN based IBW)
STEP 3

1. Flush with 30ml of water

2. (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/day

3. Flush with 30 ml water

~The End~
~Thank
You~