Read the case study then answer the following questions:

S.E. is a 24-year-old graphics designer who suffered multiple fractures when she fell from a cliff while
hiking. She has been in the hospital for 2 weeks and has no appetite. She weighed 63.5 Kg upon her arrival in
the hospital, but she has lost 4 Kg over the course of her hospitalization. Due to the nature of her injuries, she
is in traction and is immobile, although the head of her bed can be elevated 45 degrees. From the diet history,
it appears that her nutrition status was adequate before hospitalization. The health care team agrees that naso-
duodenal tube feeding should be instituted before her nutrition status deteriorates further. The standard
formula selected for the feeding is lactose-free, and nutrient requirements can be met with 2200 milliliters of
the formula per day.

What steps can be taken to prepare her for tube feeding? What are some general reasons why
nasoduodenal placement of the feeding tube might be preferred over nasogastric placement?

 After choosing the naso-duodenal feeding route, The S.E. must be prepared by the health care team before
using the feeding tube:
o The health team should discuss the procedure with the S.E. and her family members to ease any
concerns with tube feeding, And the outcome of using it.
o Discuss the reasons why tube feeding is appropriate, the benefits and risks, or any complications
that may develop during the procedure.
o Discuss the length of use of the tube feeding is temporary until S.E. can tolerate oral feeding.
o Educate them about the right position to insert tube feeding into her body and make sure she does
it well when applying it.
o After the formula arrives at the nursing station, the nursing staff is responsible for its safe
handling. Precautions include washing hands before handling formula and feeding containers,
wearing non-sterile gloves in some facilities, cleaning the lid of the feeding tray with an alcohol
swab before opening, washing the tray opener with detergent and hot water, and recording the
opening date if the entire can is not used in one meal. In the case of open feeding system these
measures are crucial to prevent the risk of infection for vulnerable individuals.
 because she is in traction and is immobile, she is at high risk of developing aspiration, and the risk
increases when using nasogastric placement more than in naso-duodenal. so that's why the naso-duodenal
was chosen instead of another type of nasal route.

What parameters should be monitored to ensure that her fluid needs are being met? How can
additional fluids be given? Estimate her fluid needs using her current weight and the fluid intake range.

 Some of the parameters should be monitored are: urine color if yellow or amber, urine specific gravity, urine
volume (by recording fluid intake and output), dry skin, and mouth as indicators on S.E. hydration status. [2,3]
 S.E. takes additional fluids through feeding tube flushes, medications, and intravenous fluids. [3]
 Fluid intake range for adults is between 30-40 ml per kg approximately (35ml per kg).
o She weighed 63.5 Kg upon her arrival in the hospital, but she has lost 4 Kg over the course of
her hospitalization. So, her current weight (59.5kg)
o 59.5kg x 35ml= 2082.5 ml per day. (4)
The physician’s orders specify that the feeding should be given continuously over 18 hours, to
determine an appropriate feeding rate.
o 2200 ml \18 hrs.= 122.2ml\hrs. (5)

What steps can the healthcare team take to prevent aspiration? Describe precautions that should be
taken if the patient is to receive medications through the feeding tube.

o To avoid aspiration, it is advisable to consider implementing the following steps: S.E. should
be positioned with her head and shoulder above her chest at least a 30- to 45-degree angle
during the feeding and for 30 minutes after the feeding whenever possible, ensure that the
feeding tube is installed correctly, use a small volume of formula and increase the volume
gradually
o Since the S.E. with continuous feeding, feeding must be stopped while taking the medication,
since medications can interact with enteral formulations in the same ways they interact with
foods. In addition, some medications may need to be exposed to the acidic stomach
environment and therefore cannot be administered via an intestinal feeding tube, ensure that
medications do not cause blockage of the feeding tubes, and flush the feeding tube before and
after taking the medication. (6)

After three days of feeding, the patient develops diarrhea. Determine possible causes. What measures
can be taken to correct the diarrhea?

o Medications are a major cause of the diarrhea that frequently accompanies tube feedings.
o Diarrhea may be caused also by malabsorption problems, bacterial overgrowth: salmonella, C-diff,
amebiasis, Rapid formula administration, or more rarely, hypertonic formulas, Malnutrition/low
serum albumin.
Measures can be taken to correct the diarrhea
o Use fresh formula every 24 hours;
o Store opened or mixed distention formula in a refrigerator
o Rinse the feeding bag and tubing before adding fresh formula
o Change feeding apparatus every 24 hours
o Prepare formula with clean hands using clean equipment in a clean environment
o Use a small volume of formula and increase volume gradually.
o Use a slow administration rate or use continuous drip feedings
o Use a small volume of dilute formula and increase volume and concentration gradually. (7)

After a week, the patient started tolerating soft jelly-like options, suggest a meal that consists of three
food options that you would offer the patient on such a diet.

o Mahalapye or sour cream(‫)شمينت‬, apple fruit in smoothie texture, blenderized vegetable soup, Jello,
pudding.
References:
(1) Rolfes, S. R. (2020) Understanding normal and clinical nutrition. Google Books. Chapter 20. Page 671-672.

https://books.google.com/books/about/Understanding_Normal_and_Clinical_Nutrit.html?
id=TwfFDwAAQBAJ
(2) Rolfes, S. R. (2020) Understanding normal and clinical nutrition. Google Books. Chapter 17. page 604.
https://books.google.com/books/about/Understanding_Normal_and_Clinical_Nutrit.html?
id=TwfFDwAAQBAJ
(3) Rolfes, S. R. (2020) Understanding normal and clinical nutrition. Google Books. Chapter 20. Page 675.
https://books.google.com/books/about/Understanding_Normal_and_Clinical_Nutrit.html?
id=TwfFDwAAQBAJ
(4) Rolfes, S. R. (2020) Understanding normal and clinical nutrition. Google Books. Chapter 20. Page 671.
https://books.google.com/books/about/Understanding_Normal_and_Clinical_Nutrit.html?
id=TwfFDwAAQBAJ
(5) Rolfes, S. R. (2020) Understanding normal and clinical nutrition. Google Books. Chapter 20. Page 674.
https://books.google.com/books/about/Understanding_Normal_and_Clinical_Nutrit.html?
id=TwfFDwAAQBAJ
(6) Rolfes, S. R. (2020) Understanding normal and clinical nutrition. Google Books. Chapter 20. Page 675.
https://books.google.com/books/about/Understanding_Normal_and_Clinical_Nutrit.html?
id=TwfFDwAAQBAJ
(7) Rolfes, S. R. (2020) Understanding normal and clinical nutrition. Google Books. Chapter 20. Page 677.
https://books.google.com/books/about/Understanding_Normal_and_Clinical_Nutrit.html?
id=TwfFDwAAQBAJ