RECONSIDERATIONS PART C

Nutritional Requirements

BEE calc:  55.1+(9.6 x 52.3) + (1.8 x 168cm) Ð (4.7 x 82) = 1074 kcal.  We 
decided not 
to multiply by an injury factor since she is not in a stress state.   But we did 
multiply by 
an activity level of 1.1 because the range is from 1.0-1.2 and we took the 
average.  This 
equals 1181kcal.  We were givin 1100 kcal as her REE.  This makes her REE:BEE 
ratio 
93%.  This shows that she is hypo-metabolic.  For feeding purposes, we are going 
to use 
the BEE.    

PRO calc:  Her euhydrated weight is 52.3 kg and we want to give her 1.0g of 
protein 
because she is marasmic and is maintaining her visceral protein stores.  This 
means we 
will be giving her 52.3 g of protein or just 52 g of protein.   

 We used the RD notebook to determine the CORRECT fluid requirements.  We 
multiplied 25ml (b/c of age) times 52.3 kg and we got 1307.5.  We rounded this 
down to 
1300ml.  

We decided to use regular Osmolite.  To determine volume of formula we divided 
1181 
by 1.06  1181/1.06= 1113 or 1110 ml.  

Since we are doing intermittent, we divided total volume by 6.  1110/6 = 185 ml 
every 
three hours.  

185 x 6 x 1.06 = 1177 kcal from formula
185 x 6 x 0.04g = 44.4 g protein  

This does not give our patient the required protein, so we can add promod.  We 
intend to 
add 2 scoops of promod total.  (we took the difference of the amount from 
formula from 
the amount required.  This gave us about 8 g deficit, which equals 2 scoops 
total).  

For initiation of day 1, we are going to begin at 120 ml q 2 h for two feeding 
sessions.  
Then we are going to increase by 60 ml for 3 feeding sessions.  For feedings 3, 
4, and 5 
she will get 180 ml.  Then her 6th feeding, which is the end of day one, she 
will meet her 
goal.  

To determine free water, we found that osmolite is made up of 84.1% water.  We 
multiplied 84.1 by the total amount of formula per day.  This equals 925 ml of 
free water.  
Since her fluid requirement was 1300 ml, we still need to provide her with 375 
ml of 
water.  This additional water will be flushed through the tube before and after 
every 
feeding session.  This means we are dividing 375ml by 12, which equals about 30 
ml 
each time.  

For monitoring, for the initiation period, we are going to monitor body weight, 
fluid I/O, 
bowel function, glucose, electrolytes, BUN, creatinine, Ca, Mg, Phosphorus every 
day.  
Following the initiation period, body weight, fluid I/O,  and bowel function 
will be 
assessed every day.  Glucose, BUN, electrolytes, creatinine, Mg, Ca, Phos will 
be 
monitored 2-3 times a week.  And albumin will be done monthly.  Liver tests will 
be 
done 1-2 times a week..  

FOLLOW UP

Since the patient was already on pureed foods PTA, she will not be able to 
tolerate finger 
foods.  This means that she could possible try pureed foods again, but most 
likely this 
will not maintain her nutritional status, therefore a permanent feeding will 
need to be 
considered. This also means that we need to consider a permanent route of tube 
feeding 
access.  We would recommend a long term PEG placement.