NUT

116BL
Winter 2016

Name: Claudia Villatoro

*******Due 2/12/16*****

Case Study #3: Critical Illness (60 points total)

You are the RD in the burn unit of your hospital. You have been consulted for a nutrition
assessment of Mr. G, and you will be responsible for follow-up assessments, planning, and
monitoring throughout his hospitalization.

Initial admission information available from the medical chart:
Mr. G, a 32 yo industrial chemist, was severely burned over much of his trunk, arms, and
back in an accident at the chemical plant where he works. After emergency first aid at the
plant, he was transported by ambulance to the university hospital burn center. Mr. G was in
shock when he was admitted.

Physical exam: Pt experiencing severe pain, moderate respiratory distress. Unburned skin
is pale and cool. BP: 90/60; P 110 and weak; RR 22 and regular; Ht: 510; pre-injury wt:
165#

Laboratory: The following tests were ordered: CBC, blood type and cross-match, Chem 20
screening panel, ABGs, and UA.

Impression: 30% TBSA (total body surface area), partial and full-thickness burns over
lower part of face, neck, upper back, arms, hands, and upper thighs.

Plan: IV therapy was initiated with Ringers lactate. A Foley catheter was inserted. Urinary
output, P, and BP monitored hourly. NPO x 24 hrs. NG tube placed for stomach
decompression. Maalox q 2 hrs through NG tube.

Initial hospital course:
As soon as the shock was under control, Mr. Gs wounds were washed, debrided, and
dressed with silver sufadiazine using fine-mesh gauze. He was given a tetanus shot
and 600,000 units of procaine penicillin were administered q 12 hrs.
After 24 hrs, Mr. Gs UO was 40-50 ml/hr and bowel peristalsis had returned;
patient is responsive to pain, but limited alertness; breathing & respiration normal
By 36 hrs, a nasoduodenal tube was placed and position of the tip verified by
radiology to be past the ligament of Trietz.
On second day (~ 36 hours), a Nutrition Consult was ordered for feeding
recommendation

Initial Assessment
Using the above information, assess the patients nutritional needs at the time of the initial
consult, on day 2 of admission.

1. Calculate Mr. Gs estimated energy needs on day 2 of hospitalization, using the following
methods. Show your work.
a. Quick shortcut as used by UCDMC burn unit [35-40 kcal/kg BW] (2 pts)
165#/ (2.2 #/kg) = 75 kg
75kg/ (35-40 kcal/ kg) = 2,625 3,000 kcal
PRG
b. TEE using Mifflin St-Jeor formula with appropriate AF and IF (2 pts)
75kg, 32 yo
510 = 70 x (2.54 cm/in) = 177.8 = 1.78m
MSJ - (10 x 75kg) + (6.25 x 177.8) (5 x 32) + 5 x (IF 1.5-1.85) x (AF 1.1)
= (750 + 1,111.25 160 + 5) x (IF 1.5-1.85) x (AF 1.1)
= 2,815- 3472 kcal
PRG

c. Comment on whether these two estimates differ or are similar, and what you
would use as your actual energy recommendation for this patient. Provide
justification for why you selected this energy recommendation. (2 pts)
Both methods are within the same ranges, but to estimate energy needs the MSJ equation would
be best to use as it takes into account the injury factor and activity factor. A higher IF and AF
will result in a higher kcal need, whereas the UCDMC uses an estimation of kcals/kg without
taking into account individual factors that can increase needs.

2. Calculate Mr. Gs estimated protein needs on day 2 of hospitalization. Show your work.
(2 pts)
1.5 2.0 g PRO/ kg BW
1.5 2.0 x 75kg = 112.5-150 g PRO
PRG

3. Discuss the effects of trauma on macronutrient metabolism. (3 points.)
Trauma causes a hyper metabolic state causing accelerated energy expenditure, which
turns the body from storing macronutrients to breaking them down for energy utilization.
Proteins are catabolized, lipids are oxidized, and the body is altered for carbohydrate
catabolism. After a trauma cytokines, ACTH, and Catecholamine are secreted that act on
the body to repair tissue and stimulate use of macronutrients for repair and energy
Lecture Notes

4. Based on the patients needs, consider the enteral formula to recommend

a. Describe two desirable features or characteristics of the type of formula you
would select and recommend. (Refer to the UCD TF lecture) (2 pt)
High protein due to high energy needs to repair tissue damage due to burns.
High concentration of calories to account for increases in energy expenditure and the high
metabolic state.
Lecture Notes
b. Give one example of an appropriate enteral formula meeting these
characteristics, using the formulary provided on the course Smartsite.(1pt)
Two Cal HN (Abbott)
Kcal 2.0kcal/mL, PRO 864g/1,000mL, H2O 70%
Formula Sheet

5. Mr. G is on IV Famotidine (Pepcid). What type of medication is this & why is it being
used? Why do you think this was used instead of the alternative Cimetidine liquid to be
put down the feeding tube? (Use the FMI text for this question) (2 pts)
Famotidine is a Histamine H2 Receptor Antagonist. It is anti ulcer, anti GERD, and anti
secretory and it is given to prevent acid fluid indigestion.
Cimetidine is not given as it precipitates tube feed, which will cause the nutrients to not be
delivered to the duodenal; can also cause pancreatitis and decrease WBC- FMI
6. Describe 3 ways you could determine the adequacy of your recommendations for energy
and protein intake for this burn patient. (In other words, what will you monitor to decide if
your recommendations are adequate, and why?) (3 points)
Monitor Nitrogen Balance in order to make sure there is enough protein intakes based on
REE and the nitrogen output is low.
Monitor an adequate energy intake to ensure that there is enough immediate energy for his
catabolic state and to help repair damaged tissues.
Monitor wound healing and skin appearance

Ongoing Assessments
It is now day 10 post-injury and you have the following additional information available:
Some wounds are still open (new estimate: 15% TBSAB). More surgery for skin
grafting is scheduled in the next week.
Diet order during the past week has been changed by MD to: Jevity 1.5 @ 60 ml/hr,
plus PO intake as tolerated.
You have conducted kcal counts for the past 3 days. They show that pt is taking 100
kcals/day by oral intake, in addition to TF. Nursing I/Os indicate that the full TF
volume is being delivered each day.

The patient tells you it is difficult for him to eat by mouth due to pain, and that he
doesnt have much of an appetite, he refuses to try eating for now.
Current BW: 70 kg, no significant edema
Current labs: albumin 2.7 g/dL, prealbumin 8 mg/dL, UUN 23 g/24 hr

7. Re-assess Mr. Gs estimated energy, protein, and fluid need using the current information
available.

a. Energy: (1 pt) Formula Sheet
MSJ - (10 x 70kg) + (6.25 x 177.8) (5 x 32) + 5 x (IF 1.0-1.5) x (AF 1.1)
= 700 + 1,111.25 160 + 5
= 1,656.25 x (IF 1.0-1.5) x (AF 1.1)
= 1,822 2,733 kcal
b. Protein: (1 pt)- Formula Sheet
70 kg x 1.5-2.0 g PRO/ kg BW = 105- 140 g PRO
c. Fluid: (1 pt)- Formula Sheet
1 mL/ kcal
1822- 2733 kcal / (1mL/kcal) = 1822- 2733 mL

8. Calculate the energy, protein, and fluid provided by the current TF regimen. Show your
work
a. Energy: (1 pt) Formula Sheet
Jevity 1.5 @ 60mL/hr 1.5 kcal/mL
60mL/hr x 24 hr = 1,440 mL/ day x 1.5 kcal/mL
= 2,160 kcal
b. Protein: (1 pt)- Formula Sheet
Jevity 1.5 @ 60mL/hr 64g PRO
64g PRO/ 1000mL = x g PRO/ 1,440mL TF
= 92 g PRO
c. Fluid: (1 pt)- Formula Sheet
Jevity 1.5 @ 60mL/hr 76% H2O
1,440 kcal x 0.76 H2O = 1,094 mL H2O

9. Calculate Mr. Gs nitrogen balance at day 10. (1 point)- PRG

Nitrogen Balance = (diet PRO intake/ 6.25) (UUN + 4)
= (92 g PRO/ 6.25) (23g/ 24hrs + 4)
= 14.72 27
= - 12.28

10. Interpret the results of the nitrogen balance study. Is current TF order adequate to
meet estimated protein needs? (2 points)
A negative nitrogen balance states that the amount of protein output is higher that the protein
intake. The 92 g PRO provided by Jevity 1.5 is not meeting the required amount of protein
that Mr. G needs due to his catabolic state. Thus, due to his 15% TBSA, his body is still in a
catabolic state: breaking down protein to replenish and repair damaged tissue due to the
burns, which Mr. G needs to be consuming 105-140 g PRO per day from REE. There is not
an adequate protein intake, so the body is using muscle protein for immediate energy and the
nitrogen, which breaks down from the protein, is excreted in the urine. - PRG

11. Write one PES statement that you will use in your note below: (3 pts)
1. Inadequate protein- energy intake (NI-5.3) r/t inadequate TF regime of Jevity 1.5
formula AEB meeting 87% protein from REE and negative nitrogen balance.

12. Write an ADIME note for your day 10 follow-up assessment of Mr. G.
Hints: Be sure to evaluate his current anthropometrics (and any trends seen), current
kcal/pro needs, adequacy of the current diet order (including both the TF and PO intake),
and current labs.
What do the anthropometric and biochemical data reveal?
Is the current diet order adequate and realistic for the patient?
Write two PES statements that reflect your assessment. In addition to the PES statement in
Q 11, write one more PES statement and include both in your note.
In the Plan section, make very specific nutrition support and monitoring recommendations
for this patient at this point in time. (23 points)

A:
32 yo male admitted to burn unit for severe burn per 15% TBSA . Post 10-day assessment
pt. awaiting surgery for skin grafting in the next week, as wounds are still open. Noted MD
consult for nutrition recommendation for tube feeding per RD.

MD Diet Order
Jevetiy 1.5 @ 60mL/hr x 24 hours
PO intake as tolerated

Anthropometrics
Ht. 1.78m
UBW 75 kg
CBW 70kg
Severe weight loss of 7% in 10 days.
IBW 75kg (93%)
BMI 22.1, normal

Labs 10 day- post surgery
Pre-albumin 8 mg/dL, low
UUN 23 g/24 hr
Nitrogen balance: -12.3, high nitrogen output, low protein intake

Medications
Famotidine(Pepcid): Histamine H2 Receptor Antagonist.
Anti-ulcer, anti -ERD, anti-secretory

Energy Requirements based on 70kg BW
Kcal MSJ: 1,822 2,733 kcal
IF 1.0-1.5 (Burns 0-20% TBSA); AF 1.1
Protein 105-140 g (1.5-2.00 g/kg BW
Fluids 1,822- 2,733 mL

Food & Nutrition Hx
Jevity 1.5 @ 60mL/ hr.
Kcal MSJ 2,160 kcal (1.5kcal/mL)- meets kcal requirement
Protein 92 g (64g/1000mL)- inadequate, proving 87% needs
Fluids 1,094 mL (76% H2O)- inadequate, administer flushes


D:
PES Statements
1. Inadequate protein- energy intake (NI-5.3) r/t inadequate TF regime of Jevity 1.5
formula AEB meeting 87% protein from REE and negative nitrogen balance.
2. Increased nutrient needs (NI-5.1) r/t hyper-catabolism from burns 15% TBSA AEB
requiring at most 2,700 kcal from REE and 1.0-1.5 g PRO/ kg per day.

I:
MNT Goal: Promote pt. wound healing and minimize catabolic loss by providing nutritional
support, adequate intake of vitamins, minerals, kcals and protein, and meet fluid
recommendations.
Recommendations
a) Diet Rx: Pt. may benefit from a more concentrated high protein tube feed formula.
Promote daytime PO with gradual increase of tolerable foods


Jevity 1.5 Modification @ 80mL/hr

TF kcal 2,000kcal

TF protein 115 g

TF fluids 1,368 mL, 250mL @ 4 times a day


Goal Regimen
Jevity 1.5 @ 75mLhr x 24 hr (= 1,800 mL, 2,700 kcal, 155 g protein, 1,368 mL free
water) + 250 mL flushes QID
b) Specific recd: Pt. will benefit from a high-energy dense formula meeting REE to
alleviate increase in energy expenditure due to hyper catabolic state.
PT will benefit from an increase in protein intake to meet REE by consuming a
complete protein formula to help restore damaged tissues and improve nitrogen balance.
c) Diet instructions given to patient of increase protein in diet, and increase kcal
concentration in formula and adequate fluid intake. Handout given to pt. that describes
in detail pt.s formula and mapped out administration of feeding and necessary flushes.
Any questions regarding medication to be addressed to MD, and TF questions addressed
to RD.
Compliance to gradual PO intake may be difficult as pt. experiences body pain, decrease
appetite, and it will be difficult to experience oral intake. Pt. will comply to new TF regimen as
it will be administer to

M/E
Monitor daily calorie counts, wound healing, tolerance to nutrition support, weight,
biochemical lab values, fluid intake and output.
Follow up with pt. 1-2 days to acquire feedback on personal well being with new administered
formula, to make sure pt. is not having further complications and meeting energy requirements
from REE.
Clincial Nutrition Student
2/11/2016

13. It is now 3 weeks since admission and he is now in a transitional care unit. Mr. Gs
wounds are closed and healing well. He is interested in trying to eat more foods orally and
his appetite is returning. How could his current continuous TF regimen (the one
recommended in your note above) be modified to provide approximately 1000 kcal/day
and not interfere with his intake at meal times? Make recommendations for an appropriate
transitional TF plan/order and how to monitor. Make a specific recommendation for both
the TF plan and monitoring. (6 points)
His current TF regimen needs to decrease in rate to administer the 1,000 kcal needed and
cycle TF at night so it does not interfere with his intake at meal times. Recommendation for
transitional feeds from TF to PO will be to adjust TF regimen based on pt.s oral intake and
intake of oral supplement and snacks monitored by accessing a diet analysis of caloric intake
and food waste and pt.s contentment with PO. Also, consider cycled TF at night and monitor
by checking the rate TF is administered.
TF regimen to be modified at 60mL/hr x 12 hours at night to provide 1,080-kcal/ day.

Calculations in ADIME note

IBW % = 70kg/75 kg x 100 = 93%
& Weight loss: 75kg 70 kg/ 75 kg x 100 = 7%
BMI: kg/ m2 = 70kg/ (1.78)2 = 22.1

Formula:
Jevity 1.5 @ 75mL/hr

Kcal= 75 mL/hr x 24hr = 1,800 mL x 1.5 kcal/mL = 2,700kcal

Protein: 64g/1,000mL = x g PRO/ 1,800 mL TF = 115 g PRO

Fluids: 1,800mL x 76% H2O = 1,368 mL
2,278 mL 1,368 mL = 910 mL ~ 1,000mL
250mL flushes QID