Meghan Keenan

Sodexo Dietetic Internships

Dietetic Intern 2019 Pre-rotation Assignment – Enteral Nutrition Support (revised May ’18)

List references you used to answer the questions at the end of this assignment

Part 1: Terminology, Medications, Lab Tests, Procedures, and Physiology Review

In your own words, define the following. We do not look for textbook answers. Focus on what is important to
know as a Nutrition Professional, future RDN.

1. Define and give examples when one would use a(n)

a. Elemental formula = AKA chemically defines/fully pre-digested, proteins and fats are broken
down to the simplest form (amino acids and MCTS) so it is easier to digest for pts with impaired
digestion and absorption (i.e. gastroparesis, gastrectomy).
b. Semi-Elemental formula = contains partially pre-digested, nutrients are partially broken down
(amino acids, simple CHO, MCTs) to aid in the digestion and absorption process.
c. Polymeric formula = intact formula, contain unaltered nutrients (whole proteins, complex CHO,
LCTGs). This formula would be given to pts with no difficulties digesting and absorbing nutrients.

2. Describe how these differ, and give an example of a patient who would benefit from them
a. Continuous Feeding = tube feeds given slowly over a number of hours, using a pump that
controls flow rate. Can take place during the day, at night, or a combination of both. This method
is beneficial for pts who cannot tolerate large portions of TF at one time and/or have
compromised GIT function because of disease, surgery, cancer therapy, etc.
b. Intermittent Feeding = tube feeds are given 3-4x/d for 20-60 minutes at a time. This can be done
with a pump or gravity drip. These feeds are often initiated for “quality of life” issues, as it allows
pts to be “off the pump” for other treatments, therapies, and activities. Often used in transition
to oral feedings and often done at night to avoid feeding at meal times.
c. Bolus Feeding = tube feeds given using a syringe to deliver formula through the feeding tube.
Bolus feedings are also often called “syringe” feeding, these are optimal for patients with
adequate gastric emptying. Usually done as a “meal” (3-4x/d) and generally takes less time to
administer (5-20 minutes) allowing more freedom for the patient. This is also much cheaper than
pump or gravity bolus feedings.

3. Below are some common access routes. Describe the access and a reasoning why it would be chosen
(think disease state, duration of feeding, etc.)
a. PEG = Percutaneous Endoscopic Gastrostomy tube. PEG tubes should be used for pts requiring
long-term feeding, who have a working gut w/no gastric motility problem. PEG tubes are
generally larger bore, facilitating medication administration and prevents clogging of tube. These
re better for children/seniors/cognitively impaired, who are likely to pull out the tube.
b. J-tube = Jejunostomy tube, feeds are administered through a tube that connects to the jejunum.
J-tubes should be used for pts requiring long-term feeding, who have a non-functional
stomach/prolonged ileus, and hx of aspiration or reflux.
c. NGT = Nasogastric tube, feeds are delivered through the start of the tube in the nose and flow
through to the stomach – these are used for short-term feedings. Pt should have a functional GIT
and low risk of aspiration if NGT are placed.

4. NG-tubes are placed bedside by nursing and sometime RDNs. Briefly describe how an NGT is placed.
How is placement of the tube verified? --- You may need to discuss with nursing or your preceptors to
 answer this.

To place an NG tube, the patient has to be sitting in bed upright (90-degree angle) and facing forward. NG
tubes are 14-18 French plastic tubes; length of tube is determined by measuring the tube from the tip of
the nose, to the earlobe and then to the xiphisternum (lower part of sternum). Once length is measured,
the tip of the tube is lubricated and inserted into one of the nostrils and into the back of the throat – the
patient will usually tell you when they feel it at back of throat. Then the patient will take a mouthful of
water and as they swallow, the tube will advance to the desired length. Tube placement is verified by
aspirating gastric contents in combination with auscultating a rush of air into the stomach or by chest x-
ray confirmation of the tube tip placement.

5. Feeding tubes can get clogged, which sometimes leads to having to replace the tube. Name some ways
how this can be prevented and if it does happen, how a clogged tube could be cleaned to avoid
replacing it.

A feeding tube can become clogged if the tube diameter is too narrow, insufficient water flushes, frequent
checking of GRVs, high protein/fiber formulas, and if medications are not adequately
administered/crushed. To clean a clogged feeding tube, one could administer warm water and move it
throughout the tube, use an enzymatic de-clogging agent (ex. Baking soda or sodium bicarbonate, or use a
device to de-clog (not for home use).

6. Aspiration Pneumonia and Gastric Residual Volumes (GRVs)

a. What is aspiration pneumonia, and how does it occur?
Aspiration PNA is an infection caused by germs getting into the lungs and airways, i.e. when a
patient breathes something in instead of swallowing it. 

b. Do GRVs play a role in aspiration pneumonia?

GRVs are the volume of fluid remaining in the stomach at a point in time during EN feeding. In
some settings, withdrawing GRVs from enteral access devices can be used to determine the risk
of aspiration PNA. However, GRVs are highly subjective and are not seen as a great marker for
aspiration PNA because the fluid is a mixture of both the infused EN formula and normal gastric
secretions. Also, there are many factors that can influence the accuracy of GRV measurements. 

c. In patients at high risk for aspiration pneumonia, what are some steps to minimize this risk?
To minimize the risk of aspiration, the head of the bed should be elevated to 30-45 degrees while
getting infusions and at least 1 hour post-infusion, monitor GRVs (if used in clinical setting) and
abdominal distension. 

d. How does nursing determine GRVs? What does nursing at your site consider a high GRV?
GRV is determined by connecting a syringe to the tube and gently drawing back the plunger of
the syringe to withdraw the stomach contents. From here, the volume of stomach contents is
recorded and the contents are injected back into the feeding tube. Nursing will then use the
syringe to flush the tube with water. Many nurses will hold feeding tubes if GRVs are greater
than 200 mL. 

e. What do ASPEN and the Academy’s EAL give as guidance on high GRVs?
 ASPEN recommends checking GRVs every 6 hours of feeding. If GRV >500 mL, ASPEN
recommends holding tube feeds for 2 hours if and rechecking GRV. After 2 hours, if GRV is <500
mL then feeding can be resumed at previous rate.

f. Also, when nursing withdraws and measures GRVs, what happens to the withdrawn stomach
content? Is there a difference when just a small amount is present versus a large amount? ---
You may need to discuss with nursing or your preceptors to answer this.
After GRVs are drawn and measured, they are ideally replaced into the patient’s stomach to
prevent fluid, electrolyte, and nutrient loss. Depending on the clinical site, a high GRV could be
anywhere from 100-500 mL. One study found that fasting volumes of a normal stomach ranged
from 0-98 mL, so a GRV of <200 would technically be considered “low” and anything above that
would be considered “high”.

7. What is Mean Arterial Pressure and how is it calculated? What is the normal range? Why is a MAP <60
mmHg a cause for concern? Why is hemodynamic stability important when planning to feed a patient
enterally?

Mean Arterial Pressure (MAP) is the average pressure in a patient’s arteries during one cardiac cycle. It
can be calculated by doubling the diastolic BP, adding the sum to the systolic BP and then dividing by 3.
The normal range for MAP is 70-100 mmHg. A MAP >60 is thought to be needed to maintain adequate
tissue perfusion (tissues are receiving enough oxygen, blood, nutrients). If MAP <60, the body may not be
able to provide enough blood to the coronary arteries, kidneys, and brain. It’s important to only initiate
enteral nutrition in patient’s that are hemodynamically stable because enteral nutrients can increase
blood flow demand and oxygen delivery on the gut. If the body is unable to support these needs due to
low MAP, it can potentially leading to gut ischemia. Gut ischemia occurs when blood flow to the intestines
decreases, due to a blocked blood vessel – lack of blood flow to the intestines can damage the tissues.

8. If a stable enterally fed patient experiences elevated Na, K and BUN with a normal creatinine, and
decreased urine output, what is a likely nutrition related cause we can correct?

These lab values and decreased urine output are most likely caused by dehydration. To fix this problem,
we can increase the amount of free water provided to the enterally fed patient.

9. Enteral feeds are sometimes blamed for the patient having diarrhea. List three potential causes of
diarrhea in a hospitalized patient on enteral nutrition support.

Many healthcare providers are apt to blame the feeding formula/volume for why their patients are
experiencing diarrhea, however there are many reasons as to why this could be occurring. Some potential
causes of diarrhea in hospitalized patient on enteral support could be due to medications, infections,
bacterial contamination, and malabsorption syndrome.

10. List at least three potential indications and contraindications for enteral nutrition support.

Three potential indications for enteral nutrition support include: malnourished pt expected to be unable
to eat for >5-7 days, well-nourished expected to be unable to eat for >7-9 days, and if pt has severe
trauma or burns. Three potential contradictions for enteral nutrition include: pt expected to eat <7-9
 days, severe acute pancreatitis, and inability to gain/maintain GI access.

Part 2: Review of MNT

In your own words, define the following. We do not look for textbook answers. Focus on what is important to
know as a Nutrition Professional, future RDN.

1. List three benefits of early enteral nutrition:

Early enteral nutrition can prevent wt loss, support immune systems, and support the functional and
structural integrity of GI tract. 

2. Why is glutamine added to some enteral formulas?

Glutamine plays a central role in nitrogen, protein, and energy metabolism. It be added to some enteral
formulas to maintain intestinal integrity and function, as many drugs deplete the body’s stores of it.
Glutamine supplementation may be effective for burn, bone marrow transplant, critical illness (trauma),
AIDS wasting patients and improve nitrogen balance in surgery.

3. Using your hospital’s enteral nutrition formulary review the article on the website where this
assignment is posted, titled, “Enteral Nutrition Formula Selection: Current Evidence and Implications for
Practice”. Pick a suitable product for the following conditions: State why you matched up the product
for that particular condition:

a. Congestive Heart Failure – Standard Polymeric formula, this formula is more appropriate for pt’s
requiring fluid restrictions because it is highly concentrated (more nutrients per mL)

b. Acute Pancreatitis -- Elemental/Semi-elemental formula, this macronutrients in this formula are

partially or fully pre-digested to improve absorption because pt may not able to produce enough
digestive enzymes and therefore may be at risk of malabsorption

c. Diabetic patients with good glycemic control – DM/Glucose intolerance formula, although the pt
may have good glycemic control it is still important to prevent fluctuations in blood glucose
levels. These formulas are lower in CHO and higher in protein, fat and soluble fiber to better
control glucose levels and prevent gastric emptying.

d. Critical Care patient with severe burns and trauma – Immunonutrition and Immune-Modulating
Formulas, these formulas supply pharmacologic active substances (i.e. Arg, Glutamine, Se,
omega-3 FAs, GLA, nucleotides, AAs) to modulate the metabolic response to stress by enhancing
the immune function

Part 3: Case Study

Jean-Luc Picard, captain of the Starship USS Enterprise (https://en.wikipedia.org/wiki/Jean-Luc_Picard) was away
on a mission when an earthquake caused a rockslide which led to traumatic brain injury. The team was able to get
him back to the ship, however a power outage caused most of their technology to be off-line and the medical staff
has to make do with 21st Century equipment.

Dr. Beverly Crusher (https://en.wikipedia.org/wiki/Beverly_Crusher) diagnosed Jean-Luc with a closed head injury
and multiple fractures, trauma present. Due to his head injury, he is being kept heavily sedated (Jean-Luc is
receiving about 350kcals a day from Propofol). He is in ventilator-dependent respiratory failure (VDRF).

58 yo male, 5’9”, 165#, BMI 24.4

Labs on admission: Na 136, K 4.2, BUN 12, CREAT 0.8, GLU 130, ALB 2.5
Tmax 39⁰ Celsius, Minute Ventilation 8 L/min

IBW:72.7 kg (162 #)  102% IBW

1. Since nutrition support is urgently needed, Dr. Crusher decides to calculate his needs using both, the
Penn State 2003b and Ireton Jones (2002) equations to compare their results. She also remembers it is
important to not overfeed a VDRF patient. Calculate his caloric needs, show your work, using:

MSJ: Mifflin St. Jeor: RMR = (9.99 x wt) + (6.25 x ht) – (4.92 x age) + 5

= (9.99 x 75) + (6.25 x 175 cm) – (4.92 x 58) + 5

= 749 + 1094 – 285 + 5  = 1563 kcal x 1.2 AF = 1876 kcal

Penn State 2003b = (MSJ times 0.96) + (Tmax in Celsius times 167) + (Minute ventilation times 31) – 6212

= (1563 x 0.96) + (39 x 167) + (8 x 31) – 6212

= 1500 + 6513 + 248 – 6212  = 2049 kcal

Ireton-Jones revised 2002 version for vented patients =

IJEE(v) = 1784 – (11 times age) + (5 times actual weight in kg) + (244 times gender use 1 for male, 0 for
female) + (239 times trauma use 1 for present, 0 for absent) + (804 times burns use 1 for present, 0 for
absent).

= 1748 - (11 x 58) + (5 x 75) + (244 x 1) + (239 x 1) + (804 x 0)

= 1748 – 638 + 375 + 244 + 239  = 1968 kcal

Does your facility have a different guideline to calculate kcal needs for VDRF patients with trauma? If so, include
the equation and the results below: N/A

2. With trauma present, calculate Jean-Luc’s protein and fluid needs. For fluid needs in this assignment,
assume 1ml/kcal.

Fluid needs: 1968 kcal x 1mL/kcal = 1968 mL/d

Protein needs: 1.5-2.0 gm/kg of ABW x 75 kg = 113-150 gm/d

3. From your hospital formulary select a suitable enteral product for Jean-Luc.
Assume a continuous feeding over 22 hours a day (allow for 2 hours TF stoppage time to provide care
and run some medical tests). Assume that the enteral nutrition pump can give simultaneous water
flushes along with the enteral formula. Make sure not to overfeed the patient. Subtract the propofol
kcals from the caloric needs you calculated above.

Total kcal = 1968 kcals - 350 kcals from propofol  = 1618 kcal

Below provide:
a. Product name you selected and why you selected it:
I choose to use Jevity 1.2 kcal because it is high protein and fiber rich, which will help to
maintain gut integrity. This formula is also a good choice for maintaining a patient’s weight.
If glucose continues to be elevated, can switch TFs to Glucerna 1.2 kcal to better manage
blood glucose.

b. Total volume of formula you administer per day:

1620 total kcal / 1.2 kcal/mL = 1348 mL/d

c. Final rate of enteral infusion to hit the goal (calculate rate over 22 hours instead of 24):

Rate = total vol of TF/22 hours  = 1348 / 22 hours = 61.2 mL/hr → Round down to 60
mL/hr for continuous pump 

d. Total kcals provided in a day:

60 mL/hr x22 hours = 1320 mL = 1.32 L
1 L of Jevity 1.2 = 1200 kcal → 1200 kcal x 1.32 L = 1584 kcal/d

1584 kcal from Jevity + 350 kcal from propofol = 1898 kcal/d 

e. Total g of protein this provides in a day:

1 L of jevity 1.2 = 55.5gm protein 
1.32 L x 55.5 gm/L = 73.26 → 73 gm/d

May need to consider adding modulars to increase protein intake and meet kcal needs

f. Total fluid from enteral formula and water flushes provided:

1320 mL x 0.81 (81% free water) = 1069.2 mL of free water 

1968 mL estimated - 1069 mL free water = 899 mL 

900 mL / 4 flushes daily = 225 mL water flush per session 

4. A week later, Jean-Luc is taken off the ventilator and Propofol and will start rehab soon. He will get PT,
OT, and ST in the mornings and afternoons. The speech therapist would like to start Jean-Luc on PO
intake of small amounts of pureed foods with honey thick liquids at lunch time. Because of the
demanding therapy schedule, Jean-Luc will get a PEG-tube to allow for continuous and bolus feedings.
Dr. Crusher asks you to create a feeding schedule where Jean-Luc’s needs can be met with overnight
feedings via pump (make sure to run it for at least 8 hours continuous so we don’t have to wake him up
for care), and some bolus feedings (one or two) during the day. You estimate that for the next week or
so, Jean-Luc will only be able to eat 200kcals or so per day for lunch with speech.
A. Revise Jean-Luc’s kcal, Pro, fluid needs (use a different equation other than what you used above
now that he is off the vent. Show your work).

MSJ: Mifflin St. Jeor: RMR = (9.99 x wt) + (6.25 x ht) – (4.92 x age) + 5

= (9.99 x 75) + (6.25 x 175 cm) – (4.92 x 58) + 5

= 749 + 1094 – 285 + 5  = 1563 kcal

TEE = REE x AF  = 1613 x 1.37 (lightly active) = 2141 kcal/d

Protein: 1-1.2 gm/kg/day  75-90 gm of protein/d

Fluid needs: 2141 kcal x 1mL/kcal = 2141 mL/d

B. Give a schedule including product name, rate, total enteral formula volume for the overnight
feeding and a schedule for the bolus feeding, again with product name and total enteral formula
volume. Make sure to also include recommended times when to run the pump / give the bolus,
and recommended water flushes.

Continue Jevity 1.2

2141 total kcal – 200 kcal from lunch = 1941 kcals from EN 

1941 kcals - 284 kcal from 1 carton for bolus = 1657 kcal for nocturnal infusion 

1657 kcal / 1.2 kcal/mL = 1380.8 mL → 1380 / 12hour feeding = 115 mL/hr for 12 hours 

1380 mL /240 mL per carton = 5.75 → 6 cartons per night 

 Plan is to run 5 cartons overnight (8pm-8am) via continuous, as tolerated, lunch at 12pm and 1 carton for
1 bolus feed during day (4pm). 

Bolus feeds: vol of each feed = (vol of formula needed) / (#of feedings per day) 

= 240 mL / 1feedings per day 🡪 = 120 mL per feeding 

 References:

Mahan, L. Kathleen., Escott-Stump, Sylvia., Raymond, Janice L. Krause, Marie V. (Eds.) (2012) Krause's
food & the nutrition care process /St. Louis, Mo. : Elsevier/Saunders

Boullata JI, Carrera AL, Harvey L, et al. ASPEN Safe Practices for Enteral Nutrition Therapy. Journal of
Parenteral and Enteral Nutrition. 2016;41(1):15-103. doi:10.1177/0148607116673053.

Carrera AL. Gastric Residuals: Are They Significant? Shield HealthCare.

http://www.shieldhealthcare.com/community/nutrition/2012/02/07/gastric-residuals-are-they-
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Chang S-J, Huang H-H. Diarrhea in enterally fed patients: blame the diet? Current opinion in clinical nutrition
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Accessed November 27, 2019.

Fessler TA. Gastric Residuals - Understand Their Significance to Optimize Care. Today's Dietitian.
https://www.todaysdietitian.com/newarchives/060210p8.shtml. Published June 2010. Accessed
November 27, 2019.

Johnson J. Aspiration pneumonia: Treatment, complications, and outlook. Medical News Today.
https://www.medicalnewstoday.com/articles/322091.php. Published June 8, 2018. Accessed November
27, 2019.

Metheny NA, Schallom L, Oliver DA, Clouse RE. Gastric residual volume and aspiration in critically ill patients
receiving gastric feedings. American journal of critical care : an official publication, American Association
of Critical-Care Nurses. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2627559/. Published November
17, 2008. Accessed November 27, 2019.

Nasogastric Tube (NGT) Insertion · Gastrointestinal · OSCE Skills · Medistudents. Medistudents.

https://www.medistudents.com/en/learning/osce-skills/gastrointestinal/nasogastric-tube-insertion/.
Published May 26, 2018. Accessed November 27, 2019.

Parrish CR. Clogged Feeding Tubes: A Clinician’s Thorn. PRACTICAL GASTROENTEROLOGY. March 2014:16-
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Accessed November 20, 2019.

https://abbottnutrition.com/jevity-1_0-cal

https://abbottnutrition.com/jevity-1_2-cal

Chapter 10 and 11 from Sodexo Internship Website