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Case Study 2 Case Questions I. Understanding the Disease and Pathophysiology 1.

The patient has suffered a gunshot wound to the abdomen. This has resulted in an open abdomen. Dene open abdomen. Open abdomen, also known as a laparostomy, is an operation in which the fascia is left open to avoid elevation of intra-abdominal pressure. It reduces the risk of patients developing systemic complications by controlling both the abdominal contents and the opening that gives access to the abdominal cavity (1).

2. The patient underwent gastric resection and repair, control of liver hemorrhage, and resection of proximal jejunum, leaving his GI tract in discontinuity. Describe the potential effects of surgery on this patients ability to meet his nutritional needs. Because JP will be unable to meet his nutritional needs through PO intake and the GI tract is in discontinuity, the patient will be a candidate for total parenteral nutrition (TPN). It is important to look at the specific type and amount of TPN and monitor if the patient is meeting adequate fluid and electrolyte needs to attain stability and then maintain balance. Following surgery, patients are experiencing stress and will have increased calorie, protein, and nutrient needs. Hypermetabolic stresses alter the metabolism of micro- and macronutrients in the body, giving reason to increase and provide supplemental nutrition to meet these needs. The effects of surgery on the digestive system will cause decreased absorption of nutrients, increased inflammation, and added stress. This can lead to nutrient deficiencies, difficulty tolerating nutrient needs and complications in the GIT and throughout the body (2). 3. Complications for this patient included anasarca. Dene anasarca and describe how this condition may affect interpretation of his nutritional status. Anasarca is excessive edema throughout the body, which happens with an increase of fluid in a very short amount of time. It is important to look at factors including the edema quality, location, and other swelling signs and symptoms when deciding how to treat the anasarca. This will cause a loss of appetite, vomiting, anemia, and water retention which are all nutrition related. Patients need to avoid salt and increase fiber in their diet (3). A variety of different lab values may be affected as a result of anasarca, including electrolytes, BUN, serum transferrin, serum albumin, serum prealbumin, and osmolality. These lab values may be misinterpreted since albumin and prealbumin are markers of protein status. When interpreting his nutritional status, you need to be aware of the electrolyte imbalance due to excess fluid retention. The excess fluid may also account for an increase in body weight, which should be considered when calculating nutritional needs. In order to accurately calculate his nutrition needs, you will need to concentrate on lab values and usual body weight while considering his actual body weight and weight changes throughout the hospitalization period to assess hydration and nutrition status (3). 4. The metabolic stress response to trauma has been described as a progression through three phases: the ebb phase, the ow phase, and nally the recovery or resolution. Dene each of these and determine how they may correspond to this patients hospital course. Ebb phase is the bodys first response to injury, beginning immediately after an injury noted by decreased oxygen consumption, hypothermia, lethargy, decreased cardiac output, decreased plasma volume,

decreased insulin levels, hyperglycemia, hypovolemia, hypotension, increased lactate, increased free fatty acids (FFA), catecholamines, glucagon, cortisol and insulin resistance. Following the injury, this phase can last anywhere from 2 to 24 hours. The most important goal during this phase is to minimize damage that could cause organ failure (2,4). After the ebb phase, about 36-48 hours following the injury, the body begins to enter the flow phase, also called the acute flow phase, noted by increased oxygen consumption, increased cardiac output, increased plasma volume, hyperthermia, increased nitrogen excretion, normal/elevated insulin levels, hyperglycemia, normal lactate, increased FFA, catecholamines, glucagon and insulin resistance. Multiple stresses result in increased catabolism and greater loss of body proteins. The flow phase is characterized by an increase in positive acute phase proteins (IL-1, IL-6, IL-8) and C-reactive protein. The most important goal during this phase is to maintain glucose levels in order to sustain gluconeogenesis, which supplies glucose to essential organs (2,4). The final phase of the metabolic stress response to trauma is the recovery or resolution phase also called the adaptive flow phase. The recovery phase is characterized by the start of anabolic processes and the restoration of lean body mass. It is noted by a return of normal lab values and stress responses that were previously elevated. Normal oxygen consumption, cardiac output, blood pressure, plasma volume, insulin levels, blood glucose levels, and decreased acute phase proteins (including C-reactive proteins) will be noted once patient has achieved this recovery phase (2,4).

5. Acute phase proteins are often used as a marker of the stress response. What is an acute phase protein? What is the role of C-reactive protein in the of critically ill trauma patients? Acute-phase proteins are liver proteins and are modified in response to injury or infection. The positive acute phase proteins that increase in number during infection, are C-reactive protein (CRP), a1antitrypson (protects cells from the inflammatory response), haptoglobin (binds hemoglobin) and fibronection. The negative acute phase proteins which decrease in number during infection include: immunoglobulin G and M (IgG, IgM), complement transthryetin, transferrin, ceruloplasmic, and albumin (2,4). CRP is a non-specific protein, which serves as a reliable indicator of the acute phase response in critically ill trauma patients and is recognized as a major indicator of inflammation. compared to albumin and prealbumin, which react immediately to inflammation and are not recommended as nutrition status for critically ill trauma patients. During the acute phase response, CRP levels dramatically increase (as much as a 50,000-fold increase in acute inflammation/infection). CRP can also be used to indicate severe infection and severe muscle wasting. Increased CRP can indicate a catabolic state indicating an overall increase in protein, calorie, and energy needs. CRP levels will return to normal when the injury heals or inflammation clears (2,4).

II. Understanding the Nutrition Therapy 6. Metabolic stress and trauma signicantly affect nutritional requirements. Describe the changes in nutrient metabolism that occur in metabolic stress. Specically address energy requirements and changes in carbohydrate, protein, and lipid metabolism.

Carbohydrate metabolism changes with metabolic stress as glucose produced in the liver is increased and mobilized to tissues (even though protein and fats are still being used for energy). There is usually more glucagon than insulin, creating a hyperglycemic response in some cases (2). Protein metabolism changes during metabolic stress with an increase in the amount needed for energy. Amino acids are converted to glucose in the liver and can then be used to produce energy. There is a decreased uptake of amino acids (AA) by muscle tissue and increased urinary excretion of nitrogen. Trauma patients often have difficulty with loss of lean body mass and negative nitrogen balance due to protein catabolism. Non essential AAs become essential in metabolic stress. For example, the nonessential AA glutamine, becomes essential during stressed states to be used as a direct fuel source by intestinal cells. Glutamine also plays a role in maintaining GI immune function, and enhancing wound repair. Protein is important because it supports AAs to promote lymphocyte and macrophage proliferation, hepatic gluconeogenesis and fibroblast function (2). Increased lipolysis occurs during stress, resulting in higher serum concentrations of free fatty acids. This happens due to the increase in circulating epinephrine, norepinephrine, cortisol, and glucagon and a decrease in insulin produced in response to stress. If patients are not adequately fed during hypermetabolic state, stores of fat and muscle can be quickly diminished, which can cause the patient to become more susceptible to infection, organ failure, and sepsis (2). According to the ASPEN Board of Directors a person experiencing trauma requires 25 to 30 kcal/kg and as much as 2 g/kg/day of protein. The patients fat intake should make up 15-40% of their total calories, and carbohydrates should increase to 60-70% of their total energy consumption. It is important to provide adequate energy to prevent using the bodys energy reserves and minimize protein catabolism by following these guidelines (4-6).

7. Are there specic nutrients that should be considered when designing nutrition support for a trauma patient? Explain the rationale and current recommendations regarding glutamine, arginine, and omega-3 fatty acids for this patient population. Glutamine, arginine, and omega-3-fatty acids are all recommended to increase when considering nutrition support for the trauma patient. Vitamin C and zinc should also be considered when planning nutrition to provide a supportive immune system due to their antioxidant properties. These nutrients resynthesize collagen, which is important in wound healing and tissue repair. DRI nutrient levels for all other vitamins/minerals should be maintained (2). Glutamine is needed for cell growth and multiplication and is therefore important during wound closure. Glutamine helps during wound closure by stimulating the proliferation of fibroblasts. It is also a precursor for nucleotide synthesis and the antioxidant glutathione, as well as a substrate for gluconeogenesis. The intake should be increased 2 to 7 times the normal recommendation for trauma patients (5,7). Arginine is used to prevent infections at the trauma site. This AA fuels the cellular immune response, and helps to increase wound immune function by excreting nitrogen and forming nitric oxide. Similar to glutamine, arginine becomes conditionally essential during stressed states, and should be increased 17 to 25 g/day during trauma, compared to the normal recommendation of 5 g/day (5,7).

Omega-3 fatty acids can aid in decreasing inflammation by decreasing production of proinflammatory cytokines and stimulating production of less-inflammatory eicosanoids. Instead of directly stimulating the immune system like arginine and glutamine, omega-3-FA compete with arachidonic acid which is important to optimize immunity. In trauma patients, adequate omega-3s could reduce ventilation, reduce the length of ICU stay, and improve patient outcomes (5,7). 8. Explain the decision-making process that would be applied in determining the route for nutrition support for the trauma patient. First, you want to assess the trauma and make sure the patient is initially stabilized before you give a nutrition assessment. You will want to determine the nutritional status prior to trauma to determine if they are at an advantage or disadvantage to recovery. Lab values and patient history prior to admission will help assess nutrition status; preexisting malnutrition may cause complications and prolonged recovery, while patients with previously good nutrition status are expected to recover at a faster, more successful rate. Assessing patients baseline nutritional status will help determine how long it will take the patient to begin receiving PO nutrition post-trauma (2). After assessing patient history and significance of trauma, it is important to determine the status of their GI function. If the GI tract is functional, enteral nutrition would be started. After assessing the function of the GI tract, it can be determined if a feeding tube should be placed, and whether it is placed directly into the stomach or into the small intestine (i.e. Naso-gastrointestinal, Dobhoff). Once determining if the patient is eligible for enteral nutrition, goals should be established to eventually reach meet all nutritional needs via PO intake. Appropriate nutritional needs are established based on the trauma, stability, and current nutritional status of the patient. Energy, macronutrients, and fluid requirements will all initially be elevated to support immune function and wound healing. By monitoring the acute phase proteins, which reflect trauma and inflammation, you can incrementally begin to decrease the needs accordingly (2,5). If the GI tract is nonfunctional, parenteral nutrition should be initiated. Access routes of TPN are determined based on the estimated length of nutrition support. It is important to monitor GI distress with tube feedings and monitor weight status to determine if the patient is receiving adequate nutrition. Patients should be monitored and administered enteral nutrition as they are stabilized, and PO intake should be reintroduced as soon as possible (2,5).

III. Nutrition Assessment A. Evaluation of Weight/Body Composition 9. Calculate and interpret the patients BMI. 10. What factors make assessing his actual weight difcult on a daily basis? The patient is currently immobile, bedridden, and on mechanical ventilation, making it difficult to obtain an actual body weight. The anasarca also causes excessive fluid retention, giving an inaccurate body weight. Additionally, the patient is constantly undergoing medical procedures and treatments due to his critical status, making it difficult and not always feasible for nurses to frequently assess his weight. B. Calculation of Nutrient Requirements

11. Calculate energy and protein requirements for Mr. Perez. Use two different predictive equations for estimating his energy needs and explain your rationale for using each one. (use minute ventilation of 10.2) Energy Requirements for usual body weight is used because you can not accurately evaluate his actual body weight due to his current trauma, anasarca, and ventilation. Ireton Jones Energy equation (Ventilator Dependent) = 2,459 kcal This is ventilator dependent, accounts for trauma, and is used for hospitalized patients. REE Mifflin-St Jeor (adults 19-78 yo) = 1,993 kcal This equation is needed to determine the Penn State equation. Penn State : = 2,567 kcal Penn State accounts for inflammatory response variation and is the most accurate if indirect calorimetry is unavailable. Protein requirements: 1.7-2.0 g/kg of protein due to current trauma status = 174 - 204 g protein needed/day. Protein demands in a multi-organ trauma patient with an open abdomen would be significantly increased. 12. What does indirect calorimetry measure? Indirect calorimetry measures the amount of heat produced by a subject by determining the amount of oxygen consumed and the amount of CO2 eliminated. If weight status is constantly fluctuating and it seems difficult to obtain an accurate representation of their nutrition, you can perform indirect calorimetry to understand what sources (fat or glucose) the patient is using for energy (2). 13. What are the indications for obtaining a metabolic cart (indirect calorimetry) for this patient? Due to the fact that JP is critically ill, on a ventilator, and experiencing anasarca, he would benefit from a metabolic cart. 14. Compare the estimated energy needs calculated using the predictive equations with each other and with those obtained by indirect calorimetry measurements. The Ireton-Jones equation predicted that JP would need 2,459 kcal/day and the Penn State Equation determined that he would need 2,567 kcal/day. JPs estimated needs determined by indirect calorimetry on day 4 were 3,657 kcals/day, and on day 10, were 3,765 kcals/day. Indirect calorimetry showed JP needed more calories than the Ireton Jones and Penn State equations estimated. The Penn State equation was higher in calories and closer to the indirect calorimetry measurement, but was still almost 1,000 calories under what the gold standard measurement calculated JPs needs to be. 15. Interpret the RQ values. What do they indicate? An RQ of 0.7- 0.8 identifies that primarily fats are being broken down and utilized for energy. An RQ between 0.9 to 1.0 indicates the body is using mostly carbohydrate. As you become more stressed, your substrate utilization will shift from 0.7 to 1.0 or greater than 1.0, showing a shift from using mostly fats and little carbohydrates, to using almost 100% carbohydrate for fuel. Mixed substrate utilization would be between 0.8-0.9 (8).

On day 4, JP had an RQ of 0.76, which implies JP was utilizing mostly lipid and some protein. On day 10, JPs RQ dropped to 0.70, implying he was using a majority of lipids as his primary energy source. 16. What factors contribute to the elevated energy expenditure in this patient? JP has a variety of factors which contribute to his elevated energy expenditure, including moderate to severe stress, multi-surgical recovery, wound healing, high risk for infections, ventilator dependency, and GI dysfunction. JP is also at risk for multiple organ dysfunction and systemic inflammatory response syndrome. Hypermetabolism is the bodys response to address all factors JP is experiencing in his current trauma and high stressed status (2). C. Intake Domain 17. Mr. Perez was prescribed parenteral nutrition and was to receive 300 g of dextrose and 170 g of amino acids per day. Determine how many kilocalories and grams of protein are provided with this prescription. Read the patient care summary sheet. What was the total volume of PN provided that day. Calculations to determine kcal needs were as follows: 300 g of carbohydrate multiplied by 3.4 kcal/g indicates 1,020 kcal total carbohydrate. 170 g of amino acids indicates 170 g of protein, and when multiplied by 4 kcal/g, reflects 680 total calories came from protein. Mr. Perez was getting 1,020 kcal from carbohydrate, and 680 kcal from protein and 924 kcal from his medication propofol, indicating a total of 2,624 kcal energy. The Penn State equation recommended was 2,567 kcal. According to the patient care summary sheet, the patient was administered 1800 ml of total PN volume at a rate of 75 ml/hr. 18. Compare this nutrition support to his measured energy requirements obtained by the metabolic cart on day 4. Based on the metabolic cart results, what changes would you recommend be made to the TPN regimen, if any? What are the limitations that prevent the healthcare team from making signicant changes to the nutrition support regimen? JPs REE on day 4 indicated that he expended 3,657 kilocalories. His nutrition support (including propofol) only provided 2624 kcal/d, leaving him with a 1033 kcal/d deficit. Recommendations should be made to the TPN regarding an increase in dextrose and amino acids to meet needs based on his metabolic cart result of an RQ of 0.76. Since his metabolic cart measurement of 107-185 mg/dL blood glucose was on the higher side, his TPN prescription should ensure a regulated carbohydrate load by providing insulin drip protocol. A limitation that may prevent the healthcare team from making significant changes to the nutrition support regiment would be the severity of JPs injures which will influence the route and composition of nutrition support that he is able to receive. With his stress and GI complications, it is important not to overfeed or provide nutrition support at a rate he cannot tolerate. 19. The patient was also receiving propofol. What is this, and why should it be included in an assessment of his nutritional intake? How much energy did it provide? The Journal of the American Dietetic Association states that propofol is a lipid-soluble, short acting IV hypnotic/sedative administered continuously to provide sedation in mechanically ventilated ICU patients. Propofol provides 1.1 kcal/ml of lipid. It is important to monitor triglycerides, lipid panel, serum turbidity,

and vital signs. When taking propofol patients are at risk of hyperlipidemia, acute pancreatitis, hypotension, increased triglycerides and cholesterol. This is important to include in the nutritional intake assessment because patients on this medication are meeting a large proportion of their daily caloric needs from propofol in the form of lipids. (9). Mr. Perez was receiving propofol at a rate of 35 ml/hr indicating he was getting 924 kcal from propofol each day. Due to the large quantity of lipids provided by propofol, additional lipids were not necessary at this time. 20. On day 11, the patient was started on an enteral feeding. If his nutritional needs were met by parenteral nutrition, why was enteral feeding started? As many nutrition professionals state, if the gut works use it. Enteral nutrition (EN) should be started as soon as possible as evidenced by fewer complications, decreased risk of infections, decreased cost, and is a more natural process by promoting healthy GI function and motility. You can prevent bacterial translocation and gut mucosal atrophy by delivering even small amounts of EN (via trophic feedings), while the patient is still primarily meeting nutritional needs through TPN. By stimulating the GI tract with EN early, we can expect a faster recovery, better patient outcomes, and hopefully, an easier transition to total EN later on. This is the next step in transitioning him to PO intake, which is the ideal end goal once the patient can meet at least 50-75% of his needs by total EN.. 21. This patient received the formula Crucial. What type of enteral formula is this? Why was this type of formula used? How many kcalories are being provided by the enteral nutrition support and what percent of his total nutritional intake does this represent? Crucial is an enteral formula for critically ill immune support. It contains arginine, glutamine, and omega-3, which are important components to help with wound healing, decreasing inflammation and promoting GI absorption. This formula was used to help address the extreme trauma and inflammation Mr. Perez is experiencing. Total nutritional support (including EN and TPN) provides 2,405 kcal total. On day 11, crucial provided 1.5 kcal/ml x 10 ml/hr rate, x 22 hours to provide 330 total kcal (13.7% of his total nutritional intake). On day 12, Mr. Perez advanced to a rate of 15 ml/hr providing him with 495 kcal total (20.6% of his total nutritional intake). On day 13, it was advanced to a rate of 20 ml/hr, providing him with 660 total kcal from Crucial (27.4% of his total nutritional intake). Mr. Perez did not tolerate the 20 ml/hr rate very well, and was brought back to a rate of 15 ml/hr for the rest of his hospital stay. 22. From the information gathered within the intake domain, list possible nutrition problems using the appropriate diagnostic terms. N.I-1.2 Increased energy intake N.I-1.4 Inadequate energy intake N.I-2.1 Inadequate oral intake N.I.-2.5 Less than optimal enteral nutrition N.I-2.8 Less than optimal parenteral nutrition N.I-3.1 Inadequate fluid intake N.I-5.1 Increased nutrient needs specifically zinc, protein, glutamine, arginine, Omega-3 N.I-5.7.3 Inappropriate intake of protein or amino acids specifically glutamine and arginine

D. Clinical Domain 23. List abnormal biochemical values and describe why they might be abnormal. Parameter Normal Value 3.5-5 Patients Value (day 4,day 10) 1.4,1.9 g/dL (Low) Reason for Abnormality Nutrition Implication

Albumin

Affected by edema, iron deficiency, wound healing, hydration status, drops with stress Catabolism in trauma and stress, hypermetabolism, breakdown of BCAA to use for energy and wound healing, parallels clinical signs of significant inflammation Drops with stress and wound healing, affected by inadequate protein and energy intake

Increased protein and energy needs; (note: albumin half life is 20 days) Increased need of TP for wound healing, Low TP may cause muscle wasting, taking AA from LBM to makeup for extreme catabolic state, may cause edema Increased protein and energy needs; sensitive to intake: use to track trends for recovery; (note: prealbumin half life 2-3 days) Monitor blood glucose, I/Os, fluid requirement, and electrolytes Hyperglycemia is expected in trauma pt, but should be closely monitored. Chronically high blood glucose may interfere with wound healing and recovery. Increased fluid/electrolyte and protein needs Increased protein needs

Total Protein

6-8

5.2, 5.1 g/dL (Low)

Prealbumin

16-35

3.0, 5.0 mg/dL (Low)

Osmolality

285-295

317 mmol/kg/H20 (High) 164,140 mg/dL (high)

Hyperglycemia, dehydration, edema, fluid/electrolyte losses Hyperglycemia in trauma, insulin resistance due to release of stress hormones, glucose being taken up by the brain instead of the cells for wound healing and stress response Fluid/electrolyte loss, dehydration, high with excessive catabolism Excessive blood loss,

Glucose

70-110

BUN

8-18

23, 25 mg/dL (high)

Creatinine

0.6-1.2

1.4, 1.6 mg/dL

(High)

dehydration, muscle wasting, protein catabolism in trauma and wound healing Decreased liver function, increased with hyperglycemia and muscle injury from trauma/stress Increased with trauma, wound healing, inflammation, decreased immunity, possible infection Needs to be monitored as part of LFT since pt on TPN, which is metabolized by the liver. Increased fluid, vitamins/minerals (C, zinc), energy, and protein needs

ALT

4-36

435 U/L (High)

WBC

4.8-11.8

15.2 x 3 3 10 /mm (High)

C-Reactive Protein

<1.0

245, 220 mg/dL (high)

Increased in response to injury Indicator of inflammation; and inflammation can indicate severe infection and severe muscle wasting

25. From the information gathered within the clinical domain, list possible nutrition problems using the diagnostic terms. Altered GI function (NC-1.4) Impaired nutrient utilization (NC-2.1) Altered nutrition-related laboratory values (glucose, albumin, prealbumin, CRP) (NC-2.2) IV. Nutrition Diagnosis 26. Select two of the nutrition problems identied in questions 22 and 25, and complete the PES statement for each. 1. Increased nutrient needs RT GSW and trauma AEB indicative lab values (low prealbumin, transferrin, TP, elevated BUN and creatinine) (NI-1.5) 2. Altered GI function RT abdominal GSW, resection of proximal jejunum and gastric repair AEB enteral formula draining from anastomotic leak, requiring TPN (NC-1.4) V. Nutrition Intervention 27. For each of the PES statements that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology). 1. Modify distribution, type, or amount of food and nutrients within feedings (ND-1.2) with increased protein and calories, while supplementing with glutamine, omega 3 and arginine to increase wound healing and decrease inflammation. Goal: Reach normal range for lab values (pre-albumin 16-35 mg/dL, Transferrin 215-365 mg/dL, BUN 818 mg/dL, creatinine 0.6-1.2 mg/dL)

Goal: Meet indirect calorimetry RQ of 0.85 Goal: Meet 50-75% of nutrient and fluid needs to minimize muscle wasting and improve wound healing 2. EN formula/solution (ND-2.2.1) Maintain current EN recommendations of Crucial 1.5 at 15 ml/hr Goal: Increase 5 ml/day EN as anastomotic leak is healed and EN is tolerated Goal: Gradual transition away from PN to full EN feeding as GI tolerance allow. Transition to PO as soon as possible. VI. Nutrition Monitoring and Evaluation 28. What are the standard recommendations for monitoring the nutritional status of a patient receiving nutrition support? - Monitor nutrition support tolerance and functional status of GIT - Monitor daily weight status and changes to assess if receiving and meeting adequate nutrition and hydration needs - Monitor S/S of under/overhydration (fluid balance, electrolytes (Na, K), In/Outs) - Monitor Indicative Lab values at least 2x/week: albumin, prealbumin, CRP, transferrin, blood glucose levels, BUN, creatinine, Mg, Ca, phosphate, cholesterol, TG, nitrogen balance - Monitor LFT (high at beginning of PN) but can progress to serious liver disease with GI abnormalities - Inspect IV access site for S/S of infection - Monitor for changes in clinical status (aware of DNI, GI fx, liver fx, organ fx) - Monitor for refeeding syndrome (slow advance to goal) - Monitor for mechanical complications at access site and catheter or EN tube

29. Hyperglycemia was noted on the patient care-monitoring sheet. List those values on day 4. Why is hyperglycemia of concern in the critically ill patient? How was this handled for this patient? Blood glucose levels on day 4 were listed in the patient care-monitoring sheet as 107-185 mg/dl. The pt summary care sheet for day 4 lists glucose levels specifically at 175, 166, 150, 150, 160, and 145 mg/dl throughout the day. The effects of stress hormones (catecholamines) causes an increase in blood glucose, glucagon and glycerol production. Due to insulin resistance in the critically ill patient, less glucose is taken up by the cells. These responses will return to normal when stress is reduced and patient begins to stabilize. Chronic elevated hyperglycemia can cause decreased wound healing, impaired patient recovery, and poor patient outcomes. The patients hyperglycemia was handled by placing him on an insulin drip protocol.

Nutrition Assessment - J.P. is a 29 year old hispanic male who works as a convenience store clerk primarily night shift (11 p.m. - 7

a.m.) - Lives with his brother, his brothers wife, and their two children - Brought to ER after vomiting blood, and bleeding wounds from abdominal area due to GSW Anthropometric Measurements Ht: 510 (70) Wt: 225 # (102.27kg) BMI: 32.3 (Obesity class 1) IBW (Hamwi): 166# +/- 10% % IBW: 135.5% (Obesity) Laboratory Values noted: Albumin: 1.9 g/dL (Low), Total Protein: 5.1 (Low), Pre-albumin 5.0 g/dL (low), Osmolality 317 mmol/kg/H20 (high), BUN 25 (high), creatinine 1.6 mg/dL (high), ALT 435 U/L (high), WBC 15.2 (high), C-reactive protein 220 mg/dL (high) Vitals: Temp 102.6 F, BP 115/65 mm Hg, HR 135 bpm/normal, RR 20 bpm Current Medications: No outpatient medications, started on morphine, lorazepam, propofol @ 35 mL/hr, esomeprazole,

meropenum, and vancomycin Current Diet: PTA does not follow any special diet. On day 3, gastrojejunostomy tube was place in patients stomach; on day 7 distal J-tube was inserted. On day 2, TPN was initiated with dextrose 300 g, and 170 g amino acids (with lipids being supplied via propofol). Dextrose was increased to 350 g and amino acids were increased on 180 g on day 4. On day 10, propofol was discontinued and IV lipids were added at 250 ml three times per week. On day 11, started enteral nutrition support (Crucial 1.5 calories per mL and 94 g protein/L) utilizing the jejunostomy tube at 10 mL/hr. On day 12, the enteral nutrition formula was advanced to 15 mL/hr, and on day 13 it was advanced to 20 mL, when it was noticed that formula was draining from anastomotic leak, and enteral feeds were decreased to 15 mL/hr where they remained. Client Hx: Smoker and family hx of CAD, wellnourished prior to admission, consumes several beers a night

and more on the weekends Calorie Needs: (Penn State) 2,567 kcal Fluid Needs:1 ml/kcal = 2,567 ml Protein Needs:174 204 g protein (1.7-2.0 g/kg) Recommendations: TPN: 350 g dextrose/day and 180 g amino acids/day (75 ml/hr) = 1,910 kcal Continue EN support: Crucial 1.5 (15 ml/hr) until tolerated then increase to 20 ml/hr = 495 kcal Provide 250 ml lipid 3x week Nutrition Diagnosis 1. Increased nutrient needs RT severe wound healing, protein catabolism, hypermetabolism, and extreme inflammation AEB indicative lab values (low prealbumin, transferrin TP, elevated BUN and creatinine) (NI-1.5) 2. Altered GI function RT abdominal GSW, resection of proximal jejunum and gastric repair AEB enteral formula draining from anastomotic leak, requiring TPN (NC-1.4)

Nutrition Intervention

1. Modify distribution, type, or amount of food and nutrients within feedings (ND-1.2) with increased protein and calories, while supplementing with glutamine, omega 3 and arginine to increase wound healing and decrease inflammation. Goal: Reach normal range for lab values (pre-albumin 16-35, Transferrin 215-365, BUN 8-18, creatinine 0.6-1.2) Goal: Meet indirect calorimetry RQ of 0.85 Goal: Meet 50-75% of nutrient and fluid needs to minimize muscle wasting and improve wound healing 2. EN formula/solution (ND-2.2.1): Maintain current EN recommendations of Crucial 1.5 15 ml/hr Goal: Increase 5 ml/day EN as anastomotic leak is healed and EN is tolerated Goal: Gradual transition away from PN to full EN feeding as GI tolerance allow and meeting at least 50-75% of estimated needs. Begin transition to PO as soon as possible (once meeting at least 5075% needs EN).

Monitoring and Evaluation ! Monitor lab values including albumin, prealbumin, CRP, transferrin, BUN, creatinine, blood glucose levels, Mg, Ca, Phosphate, cholesterol, TG, Nitrogen Balance ! Monitor tolerance of nutrition support, functional status of GIT ! Monitor weight status, S/S of under/overhydr ation (fluid status, electrolytes, In/Outs) ! Order metabolic cart and assess caloric intake/needs as tolerance is increased ! Inspect IV access site for S/S of infection ! Monitor for changes in clinical status (aware of DNI, GI fx, liver fx, organ fx) ! Monitor for refeeding

syndrome (slow advance to goal) Monitor for mechanical complications at access site and catheter or EN tube

KDeangelis, GMcConville, KMagoffin, KPruettTatum, Student NC, 11/13/12 4:15 pm

References:

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