NUT 116BL Name: ______________Krista

Sedgwick___

Major Case Study: Critical Illness & Nutrition Support

(11 questions; 60 points total)

Due 2/17/17 by 11 am
Submit Case Study online;
Turn in typed hard copy of ADIME note

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, 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 12 hrs or until hemodynamic stability achieved.
NG tube placed for stomach decompression. Maalox q 2 hrs through NG tube and IV
Famotidine..

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 18 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 24 hrs, a nasoduodenal tube was placed and position of the tip verified by
radiology to be past the ligament of Trietz.
On morning of second day (~ 30 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. Which of the following statements best describes your nutrition screening of Mr. Gs
risk level? (1 pt)

_____ Minimal risk (patient is at or above IBW, no weight loss prior to admission); no
specialized nutrition therapy over the first week of hospitalization is required.

_____ Moderate risk (patient is at or above IBW, no weight loss prior to admission);
limited alertness duration likely > 72 hours; trophic feeds recommended to be started
within 48 hours of admission and continued through first week of hospitalization.

_____ __X__ High risk (patient is at or above IBW, no weight loss prior to admission) Formatted: Font color: Red
with high injury severity; enteral feeds recommended to be started within 48 hours of
admission; enteral nutrition support recommended to provide >80% of goal energy &
protein needs.

_____ High risk (patient is at or above IBW, no weight loss prior to admission) with high
injury severity; trophic feeds recommended to be started within 48 hours of admission;
parenteral nutrition support recommended to provide >80% of goal energy & protein
needs.

2. Calculate Mr. Gs estimated energy needs on day 2 of hospitalization, using the

following methods. Show your work.
a. Quick shortcut per the ASPEN Critical Care Guidelines [25-35 kcal/kg BW] (2
pts)
a. Formatted: Indent: Left: 0.75", No bullets or
25kcal x 75kg= 1,875kcal numbering
35kcal x 75kg= 2,625kcal 1,875kcal-2,625kcal Formatted: Font color: Red
Formatted: Font: Bold, Font color: Red
b. TEE using Mifflin St-Jeor formula with appropriate AF and IF (2 pts)
Formatted: Font color: Red

(10 x wt) + (6.25 x ht)-(5 x Age)= (10 x 75kg) + (6.25 x 177.8cm)-(5 x 32)= 1,701 Formatted: Font color: Red
IF= 1.50-1.85 x 1,701kcal= 2,551.5-3,146.9kcal x 1.1 = 2,806.7-3,461.5kcal Formatted: Font: Bold, Font color: Red
AF=1.1
Formatted: Font color: Red

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)

The estimates differ, and I would use the ASPEN value because this is closest to the
number of calories I get when I calculate using curreri. Also, ASPEN is more specific to
critically ill pts. Formatted: Font color: Red
3. Calculate Mr. Gs estimated protein needs on day 2 of hospitalization. Show your work
and provide a goal range. (2 pts)
3. Formatted: Indent: Left: 0.25", No bullets or
1.5-2g/kg/d= 112.5g/d-150g/d numbering

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)
We would want a formula that best meets caloric, protein, and micronutrient goals as well
as takes into account modified fluid or electrolyte composition (TF Lecture). For this pt we
want a higher protein formula w/ glutamine, arginine, and omega-3. Whey is the best Formatted: Font color: Red
source for protein (MNT PG pg 96) Vitamin and mineral needs are also very important for Formatted: Font color: Red
this pt (NTP pg 680)
Formatted: Font color: Red

b. Give one example of an appropriate enteral formula meeting these Formatted: Font color: Red
characteristics, using the UCDMC formulary provided on the course web
site.(2pt)

Nepro with Carb steady is high protein and high calorie which is important for a burn pt.

*NTP pg 678 Formatted: Font color: Red

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 Cimetodine liquid to
be put down the feeding tube? (Use the FMI text for this question) (2 pts)

Antiulcer, antiGERD, antisecretory mediaction and it is being used instead of Cimetodine Formatted: Font color: Red
because Cimetodine liquid precipitates tube feeding

*FMI pg 166

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)

1. Changes in body wt Formatted: Numbered + Level: 1 + Numbering Style: 1,

2. Glycemic control 2, 3, + Start at: 1 + Alignment: Left + Aligned at:
3. Albumin and pre-albumin 0.25" + Indent at: 0.5"
*NTP pg 669 Formatted: Font color: Red

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 1.2 @ 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 needs using the current
information available.

a. Energy: (2 pt)

25kcal x 70kg= 1,875kcal

35kcal x 70kg= 2,625kcal =1,750kcal-2,450kcal Formatted: Font: Bold

b. Protein: (2 pt)

1.5-2g/kg/d= 105g/d-140g/d Formatted: Font: Bold

Formatted: Font color: Red
c. Fluid: (2 pt)

1ml fluid/kcal= 1,750ml-2,450ml Formatted: Font: Bold

Formatted: Font color: Red
8. Calculate the energy, protein, and fluid provided by the current TF regimen. Show your
Formatted: Indent: Left: 0"
work. Jevity 1.2 @ 60 ml/hr, plus PO intake as tolerated. 60ml/hr x 24 hr= 1,440 ml/d
a. Energy: (2 pt)
a. Formatted: Indent: Left: 1", No bullets or numbering
1.2kcal/ml x 60ml/hr= 72kcal/hr x 24hr= 1728kcal/d + 100 Kcal oral= 1,828kcal/d Formatted: Font color: Red
Formatted: Font: Bold, Font color: Red
b. Protein: (2 pt)
Formatted: Font: Bold
60ml/hr x 24 hr= 1,440 ml/d Formatted: Font: Bold, Font color: Red
55.5gPro/L x 1,440ml/1000L= 79.9gPro/L Formatted: Font color: Red
Formatted: Font color: Red
c. Fluid: (2 pt)
Formatted: Font: Bold
.807 x 1,440ml/d= 1,162.1ml water/d Formatted: Font color: Red
Formatted: Font: Bold
9. You calculate Mr. Gs nitrogen balance at day 10, using the formula and values given
Formatted: Font color: Red
below.

N balance = g protein (UUN + 4) = 92 g pro (23 g + 4) = - 12.3 g N/d

6.25 6.25
 Interpret the results of the nitrogen balance study above. Is the current TF order adequate
to meet estimated protein needs? (2 points)
The negative value is a marker of metabolic stress or skeletal muscle catabolism which
is to be expected in burn pts. This value is very low and when looking at the calculated
values the suggested protein amount is not being met, so the current TF order is not
adequate.

*NTP pg 668-669

10. Write an ADIME note for your day 10 follow-up assessment of Mr. G. (22 points)
Hints: Follow the ADIME note guidelines provided on the course web site. Use
subheadings. 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 a PES statement that
reflects your assessment and include it in your note. In the Plan section, make very
specific nutrition support and monitoring recommendations for this patient at this point in
time.
.
*REMEMBER to turn in hard copy of your typed ADIME note & attach a calculations sheet
to your note; remainder of the assignment is to be submitted online

11. It is now 3 weeks since admission and Mr. G is now in a transitional care unit. Mr. Gs
wounds are closed and healing well. He is finally 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 a total of 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 total)

(4 pts) Recommended transitional feeding plan

My recommendation is TF during the night and oral feed during the day. This way he still Formatted: Font color: Red
has an appetite to eat while he is awake unlike if I were to TF between or through meals.
Oral foods should be nutrient dense.
*NUT 116BL Nutrition Care Critical Illness Lecture slide 27 Formatted: Font color: Red

(2 pts) Monitoring plan

Calorie counts can be used to monitor caloric intake. Once he has met 75% of his Kcal Formatted: Indent: First line: 0"
needs TF can cease.

*NUT 116BL Nutrition Care Critical Illness Lecture slide 27 Formatted: Font color: Blue
A:

Pt History: 10 day follow up for 32yo Male admitted w/ severe chemical burns over trunk,
arms, and back.

MD Diet Rx: Jevity 1.2 @ 60 ml/hr, plus PO intake as tolerated.

Anthropometrics: Ht: 510, CBW: 70kg, IBW: 75.5kg, % IBW: 93%, BMI: 21.8 (nl), lost
5kg BW

Wt Hx: pre-injury wt: 75kg, Lost 5kg BW, % change BW: 6.7%

Overall Appearance: 15% TBSAB, some wounds still open partial and full-thickness
burns over lower part of face, neck, upper back, arms, hands, and upper thighs. No
significant edema.

Cognition: Awake and responsive, refuses to try to eat for now d/t pain and loss of
appetite

Skin: burns on trunk, arms, and back: 15% TBSA

Biomedical Data/labs: albumin 2.7 g/dL, prealbumin 8 mg/dL, UUN 23 g/24 hr

Medications: IV famotidine

Estimated Energy Needs

Energy: 1,750kcal-2,450kcal
Protein: 105g-140g/d
Fluid: 1,750ml-2,450ml

Food and Nutrition Hx:

D1: NPO x 12hrs or until hemodynamic stability achieved. Maalox q 2 hrs through NG
tube. After 24 hrs nasoduodenal tube placed.
D 2: (~30 hours) Nutrition consult ordered.
D 10: Jevity 1.2 @ 60 ml/hr, plus PO intake as tolerated. Kcal counts for past 3 d show
that pt is taking 100 kcal/d by oral intake.

D:
Unintended wt loss (NC-3.2) r/t TF not meeting increased energy needs for wound healing
AEB loss of 5kg BW in 10 ds.

I:
Goal: Promote wound healing and minimize catabolic loss through appropriate energy
intake
Specific Recommendations:
 Use high protein formula to (>20-25% of total calories)
Administer adequate kcal
Supplement Vitamin A (5000 IU/1000kcal), C (500mg/2x/d), E, and zinc (220mg/d
zn sulfate), Arginine (2% tot kcal), and glutamine(.3-.4g/kg/d)
Increase omega-3

M/E:
Monitor daily calorie counts and be sure that feeding is not interrupted enough to decrease
caloric intake. Check wt as well as monitor biochemical lab values to be aware of
catabolism.

Calculations:
BMI: 70kg/(1.8m2)=21.6
IBW: 106# +60#= 166#
CBW: 70kgx2.2=154#
%IBW: (154#/166#) x 100= 93%
Curreri: (25kcal/kg x wt) + (40 x %TBSA)%TBSA= (25kcal/kg x 70kg) + (40 x 15%)=
2,350kcal
ASPEN: 25kcal x 70kg= 1,875kcal
35kcal x 70kg= 2,625kcal
Pro: 1.5-2g/kg/d= 105g/d-140g/d
Fluid: 1ml fluid/kcal= 1,750ml-2,450ml
% change BW: 75kg-70=5kg/75 x 100= 6.66%
Formatted: Indent: First line: 0"