NUT 116BL Name: Akarin Mittongtare

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.

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) 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)

75 (kg) x (25-35kcal/kg BW) = 1875kcal 2625kcal

b. TEE using Mifflin St-Jeor formula with appropriate AF and IF (2 pts)

10 x 75 (kg) + 6.25 x 177.8 (cm) 5 x 32 (y) + 5 x (1.1 AF) x (1.50-1.85 IF) =

2815kcal 3472kcal

PG pg. 3

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 two estimates, Mifflin St-Jeor and ASPEN, differed greatly; almost by 1000 kcal.
Using Mifflin St-Jeor would be ideal in the actual energy recommendation as it takes
many more physical factors into consideration such as age, height, physical activity, and
possible injuries, which ASPEN does not. This makes it much more accurate in
determining energy recommendations.

3. Calculate Mr. Gs estimated protein needs on day 2 of hospitalization. Show your

work and provide a goal range. (2 pts)

1.5-2.0 g/kg/d x 75 kg BW = 112.5g 150g protein/d

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)

With Mr. G in this condition, two desirable features we are looking for are:

1. Energy + protein in order to account for muscle loss and energy needs in the
patient.

2. Osmolality that determines that the formula can be tolerated by the patient as
it can cause poor side effects such as diarrhea if the formula is too
hypertonic.

b. Give one example of an appropriate enteral formula meeting these

characteristics, using the UCDMC formulary provided on the course web
site.(2pt)

Jevity 1.2 Cal meets these characteristics of high protein (55.5 gm/L) and energy (1.2
kcal/L) to meet his TEE needs, as well as an ideal osmolality. There is also an adequate
amount of CHO so that Mr. G wont use up all his protein for energy and instead also use
energy from glucose.

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)
Pepcid is a hsitimae-2 blocker that lowers the amount of stomach acid produced in the
body. As a burn victim, Mr. G is experiencing hyper metabolism, which is causing an
excessive breakdown of the macronutrients he needs in order to heal. By reducing the
amount of stomach acid, Mr. Gs body can make use of the macronutrients he
consumes PO and through TF. Since hyper metabolism needs to be treated quickly,
Famotidine is a better choice than Cimetodine which is slower in reducing stomach acid.
Cimetodine also precipitates in tube feeding which can cause complications during
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)

In order to determine adequacy of energy and protein intake, I would monitor:

1. Mr. Gs daily calorie count in order to determine if he is meeting nutritional energy

goals via dietary logs including tube feeding. Compare with his recommended
needs.
2. Lab values that reflect nutrition status such as albumin and prealbumin in order
to determine possibility of malnutrition. If levels are low, this could be a result of
protein deficiency.
3. Nitrogen balance to assess adequacy of protein and energy source.

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)

10 x 70 (kg) + 6.25 x 177.8 (cm) 5 x 32 (y) + 5 x (1.1 AF) x (1.0 - 1.5 IF)

= 1822kcal 2733kcal

PG pg. 3

b. Protein: (2 pt)
1.5 2.0g/kg/d x (70kg BW) = 105g 140g protein/d
PG pg. 5

c. Fluid: (2 pt)

1 mL fluid/kcal x (1822kcal 2733kcal) = = 1822kcal 2733kcal=

PG pg. 6

8. Calculate the energy, protein, and fluid provided by the current TF regimen.
Show your work
a. Energy: (2 pt)

(1.2kcal/mL) x (60mL/hr) x (24hr/d) = 1728kcal/d

b. Protein: (2 pt)

55.5g protein/L x (60ml/hr) x (1L/1000ml) x (24hr/d) = 79.9 protein/d

c. Fluid: (2 pt)

(1728kcal/d)/(1.2kcal/mL)= 1440mL fluid x (0.807 water) = 1162 mL

Requires: 1728 kcal/d x (1mL/1kcal) = (1728 mL 1162 mL) = 565.92 mL of free
water

9. You calculate Mr. Gs nitrogen balance at day 10, using the formula and values given
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)

Mr. Gs current nitrogen balance is at negative which means his output of nitrogen is
greater than that of his input/intake. This is all while he is in a catabolic state. This may
be the result of Mr. G not consuming adequate amounts of protein causing an even
more catabolic result. A negative nitrogen balance may also indicate he is breaking
down protein as an energy source causing an elimination of more nitrogen than normal
meaning increased nitrogen loss. Ideally, Mr. G would increase his protein intake in
order to prevent increased muscle breakdown, but the nitrogen balance value may not
be entirely accurate as it doesnt not account for oral intake and nitrogen loss caused by
wounds as they are unmeasurable.

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

2/16/2017 6:00 PM

A:
Patient Hx:
32 yo M admitted for severe chemical burns located on the arms, back, and trunk,
due to a work-related accident 10 days prior.

Anthropometrics:
CBW: 70kg
IBW: 75.7kg
%IBW: 92.7%
Ht: 177.8cm
BMI: 22.1, normal BMI
Wt Hx:
Loss of 5kg after injury

MD Diet Order: Continuous enteral tube feeding of Jevity 1.2 Cal at 66.6 mL/hr while
continuing oral intake as pt can tolerate.
 Physical Exam, Nutrition Focused:
Cognition Alert
Skin TBSAB 15%, some open wounds
GI Difficulty consuming food PO
Overall Pt is showing signs of improvement

Lab:
Albumin: 2.7g/dL
Prealbumin: 8mg/dL
UUN: 23g/d

*Lab values are low due to pt hyper metabolism and insufficient nutrient
proficiency from TF.

Medication:
IV Famotidine, Pepcid
Maalox q 2hs thru NG tube

Nutrient Needs:
Energy: 1822kcal 2733kcal
Protein: 105g/d -140g/d
Fluid: 1822mL 2733mL

Food and nutrition Hx:

Pt shows difficulty eating PO d/t pain and refuses to consume food orally
o Pt has only been consuming 100kcal/d PO for the past 3 days
Nutrients supplied via TF delivered:
o Energy: 1728kcal/d (low end of wnl)
o Protein: 79.9g/d (low which can be seen by Nitrogen balance which
is negative, - 12 N/d)
o Fluid: 1162 mL (low so must flush 565.92 mL of free water into Mr.
G daily)

D:

Increased need for nutrient protein (NI-5.1) d/t hyper metabolism caused by chemical
burns inflicted on pt body AEB by low intake of protein (79.9 g/d protein).

I:
 MNT Goal: Incorporate ideal TF formula into pt diet in order to make up for
existing nutrient inadequacies as well as meet energy and nutrient
requirements for optimal healing.

1.Change formula from Jevity 1.2 Cal to:

Osmolite 1.5 Cal:
Energy: 2160 kcal/d
Protein: 90.3 g protein/d
Fluid: 1097 mL fluid/d
Supplement with protein supplement Glutamine, 0.3 - 0.5g/d
2. Provide instruction so that pt can supply nurse with information on
whether or not he would like to consume food PO.

Pt currently not compliant with eating food PO but is willing to receive nutrients via TF.

M/E:
Monitor:
1. Wt daily to ensure pt is receiving sufficient nutrients
2. Lab data including prealbumin, albumin, and UUN in order to monitor sufficient
protein intake
3. Skin health in order to ensure fluid is not being lost through pt wounds.
4. Energy received via TF formula to ensure sufficient energy intake.

Follow up every 1 week via in-person check-ins.

Signature: Akarin Mittongtare, Nutrition Student, February 16, 2017

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

Modify the TF regimen as follows:

666 mL x (1.5kcal/mL) = 1000kcal

666 mL/10 hrs = 66.6 mL every hr for 10 hrs
The recommended transitional feeding (TF) plan would be TF at night while the pt is
asleep and PO during the day so that Mr. G, the pt, can consume as many nutrients as
he can orally throughout the day. Since the pt is having difficulty consuming food orally,
this EN plan will allow roughly 1000kcal at night as a baseline while he slowly gets used
to consuming food orally again.

(2 pts) Monitoring plan

TF should be initiated continuously, but also slowly overnight. Begin EN of Osmolite 1.5
Cal at 66.6 mL/hr for 10 hrs; ideally overnight between the hours of 8pm 6am so that
EN can be stopped 2 hours before breakfast at roughly 8am. This should provide Mr. G
with roughly 1000kcal, 41.8 g of protein and 457.2 mL of fluid. Kcal, protein, and fluid
levels should be monitored to make sure TF is adequate in meeting nutrient
requirements as remaining nutrients are consumed orally throughout the day.

CALCULATIONS:

Ht: 178.8cm
Wt: 70kg

BMI = (70kg/1.778m2) = 70/3.16 = 22.1 kg/m2 (normal BMI)

IBW = 106 + 6 x 10 = 166 x (1 kg/2.2) = 75.5 kg

% IBW = 70kg/75.5 kg x 100 = 92.7%

Jevity 1.2 Cal:

Energy: (1.2 kcal/mL) x (60mL/hr) x 24hr = 1728 kcal/d

Protein: (55.5 g/L) x (60ml/hr) x (1L/1000mL) x (24hr/d) = 79.9 g Pro/d

Fuid: (60mL/hr) x 24hr = (1440 mL) x (0.807) = 1253 mL fluid

Free Fluid (H2O): 1728 kcal/d x (1mL/1kcal) = 1728 mL 1253 mL = 475 mL

Osmolite 1.5 Cal: (Problem 11 + ADIME)

Energy: (1.5 kcal/mL) x (60mL/hr) x 24hr = 2160 kcal/d

Protein: (62.7 g/L) x (60ml/hr) x (1L/1000mL) x (24hr/d) = 90.3 g Pro/d

Fuid: (60mL/hr) x 24hr = (1440 mL) x (0.762) = 1097 mL fluid

Free Fluid (H2O): 1728 kcal/d x (1mL/1kcal) = 1728 mL 1097 mL = 631 mL