NUT 116BL Name: Sidra Ansari

Major Case Study: Critical Illness & Nutrition Support

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)
BMI = (165#/2.2#)/(70 in x 2.54 cm/100 cm)^2 = 75 kg/(1.778 m)^2 = 75kg/3.1628 m^2
~ 24 > Normal BMI

75 kg x 25 kcal/kg = 1875 kcal

75 kg x 35 kcal/kg = 2625 kcal

~1875 - 2625 kcal

PR pg 1, 3
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) + 5
750 + 1111.25 - 160 + 5
1706.25 kcal

1706.25 x 1.1 x 1.50 = 2815.3125 kcal

1706.25 x 1.1 x 1.85 = 3472.21875 kcal

~2815 - 3472 kcal

PR pg 3, 5
 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 range obtained from the ASPEN Critical Care Guidelines (1875-2626 kcal) method
was much lower than the range obtained from the Mifflin St-Jeor formula (2815-3472
kcal). In fact there is almost a difference of a 1000 kcal. I would choose the Mifflin St-
Jeor since the values are higher and Mr. G is a burn patient and will therefore have
more energy requirements so that he can heal and rebuild his body. Another important
note is that the Mifflin St-Jeor equation takes into account that he is confined to bed
(AF) and has 30% TBSAB (IF).

PR pg 3, 5
3. Calculate Mr. Gs estimated protein needs on day 2 of hospitalization. Show your
work and provide a goal range. (2 pts)

75 kg x 1.5g/kg = 112.5 g/d

75 kg x 2.0g/kg = 150 g/d

~112.5-150 g Pro/d

PR pg 5
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)
1) First of all the formula needs to be higher in calories so that the patient can
compensate for his higher energy needs since 30% of his body is burned.

2) Also, the pt will need a formula that is higher in protein so he can have what he needs
to begin the healing process and also to make for what he lost from the burns.

NUT 116Bl EN Support Slides 21-24

b. Give one example of an appropriate enteral formula meeting these
characteristics, using the UCDMC formulary provided on the course web
site.(2pt)
One example of an appropriate enteral formula is TwoCal HN because it has a high
caloric density at 2 kcal/mL and a high protein content at 83.5 gm Pro/L.
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 an Histamine H2 Receptor Antagonist that is an antiulcer, antigerd, and

antisecretory medicine that can be given orally or through an IM or IV. The primary
reason for the use of Pepcid is to prevent Curlings Ulcers that burn and trauma patients
can get. In that case you would most likely want to suppress acid secretion to prevent
further aggravation. The reason that Cimetidine has not been used for tube feeding is
because it can cause precipitation in the tube.

FMI pg 140, 166, 167

NTP pg 666
NUT 116Bl Nutrition Care Critical Illness Slide 22
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) Weight The weight of the patient should be monitored to ensure that he is meeting
his energy needs to heal. If his weight is decreasing then this could mean that the
formulas being used either isn't sufficient in the type or the amount being fed.
2) Nitrogen Balance Mr. Gs UUN should be monitored so that values for his nitrogen
balance can be obtained. If his nitrogen balance is positive, then this means he is
meeting his protein needs, which is what we want so that he can heal. But if it is
negative then we will know that the TF regimen he is on is not adequate and we can
change it appropriately.
3) I/O The amount that he is taking in and the amount that he is excreting should be
assessed to determine the sufficiency of his TF regimen. If he is not meeting his needs
then the formula or regimen will need to be changed to ensure a proper healing and
rebuilding process.

NUT 116Bl Nutrition Care Illness Slide 14

NTP pg 57
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) + 5
700 + 1111.25 - 160 + 5
1656.25
1656.25 x 1.1 x 1.0 = 1821.875
1656.25 x 1.1 x 1.5 = 2732.8125

~1822-2733 kcal

PR pg 3,5
b. Protein: (2 pt)

70 kg x 1.5 g/kg = 105g

70 kg x 2.0 g/kg = 140g

105-140 g Pro/d

PR pg 5
c. Fluid: (2 pt)

1822 kcal x 1 mL fluid/kcal = 1822 mL

2733 kcal x 1 mL fluid/kcal = 2733 mL

1822-2733 mL fluid minimum per day

PR pg 6
8. Calculate the energy, protein, and fluid provided by the current TF regimen. Show
your work
a. Energy: (2 pt)
Jevity 1.2 60 mL/hr

24 hr x 60 mL/hr X 1.2 kcal/mL = 1728 kcal

NUT 116Bl Enteral Support Slides 21-24

b. Protein: (2 pt)
24 hr x 60 mL/hr x 1 L/1000 mL x 55 g Pro/L = 79.92 g Pro ~ 80g Pro

NUT 116Bl Enteral Support Slides 21-24

c. Fluid: (2 pt)
24 hr x 60 mL/hr = 1440 mL

0.807 x 1440 mL = 1162.08 mL fluid ~ 1162 mL fluid

NUT 116Bl Enteral Support Slide 59

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)
A negative nitrogen balance means that Mr.G is excreting more nitrogen than he is
taking in. This indicates that he could be in a catabolic state and is not getting enough
protein to meet his needs. This can be confirmed by the fact that the Jevity 1.2 formula
gives him about 80g of protein a day which does not even meet the absolute minimum
of a 105g of protein that he needs.

NTP pg 57
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

Assessment

Pt Hx: 32 yo M admitted to burn center for severe burns 30% TBSAB, s/p 15% TBSAB
after 10 days
MD Diet Order/Rx: Jevity 1.2 @ 60 mL/hr (1728 kcal, 80 g Pro, 1162 mL) & PO intake
as tolerated
Anthropometrics: 5 10, UBW 75 kg, CBW 70kg, IBW 75.5 kg, IBW% 99%, 6.7% wt
loss (severe), BMI 22 nl
Overall Appearance: Some wounds still open ~15% TBSAB
GI: Has peristalsis
Cognition: Awake and talking
Skin: Some wounds still open 15% TBSAB noted, no significant edema
Biomedical Lab Data: UUN 23g/24 hr
Medication: IV Famotidine (Pepcid), Maalox q 2hrs, Ringers lactate
Estimated Nutrient Needs (based on 70 kg wt)
Energy: ~1822-2733 kcal
Protein: 105-140 g Pro/d
Fluid: 1822-2733 mL fluid min per day
Food and Nutrition Assessment: refuses to eat b/c poor appetite & difficulty eating d/t
pain

PR pg 1-3, 5, 6
NUT 116Bl Enteral Support Slides 21-24, 59

Diagnosis

Inadequate protein intake (NI-5.7.1) r/t lower protein content of Jevity 1.2 Cal AEB by N
balance value of -12.3 g N/d.

Inadequate energy intake (NI-1.2) r/t insufficient diet order of Jevity 1.2 Cal AEB by
6.7% (severe) wt loss.

Intervention

1) To increase energy and protein intake through TF w/i ranges of 1822-2733 kcal and
105-140 g Pro/d to promote recovery

2) Specific Recommendations
New Diet Rx: TwoCal HN initiate 20 mL/hr, advance 20 mL/hr p 4-6 hours or as tol
and then advance 15 mL/hr to reach goal rate of 55 mL/hr (2640 kcal, 110 g Pro/d,
924 mL fluid)
Recommend 240 mL water flush Q6 hours (=960 mL/d) to give total of 1884 mL fluid/
d
PO intake as tol

NUT 116Bl Enteral Support Slides 21-24, 58-61

Monitoring/Evaluation
1) order pt UUN values to monitor nitrogen balance to ensure pt is receiving adequate
protein
2) monitor wt to see if pts nutritional needs are being met (if wt loss then may need to
change TF regimen)
3) Monitor I/O to determine how much of diet order is being delivered to pt
4) see if any PO intake or whether will try PO as tol

NUT 116Bl Nutrition Care Illness Slide 14

NTP pg 57

Sidra M. Ansari 2/17/17 Nutrition Student

Refer to Calculation Sheet at end for all calculations

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
1000 kcal/(2kcal/mL) = 500 mL

Want to switch to cyclic feedings at night from 10:00pm-8:00 am

10 hr x 50 mL x 1L/1000mL x 83.5 g Pro = 41.75 ~ 42g Pro/d

0.70 x 10 hr x 50 mL = 350 mL water

Diet Order: Promote TwoCal HN 50 mL/hr X10 hr at night from 10:00pm-8:00am

An appropriate transition TF plan/order would be for Mr.G to be switched from

continuous feedings to cyclic feedings at night to get a minimum of 1000 kcal and get
the rest of his energy needs from PO. This way he can be encouraged to wean off the
continuous enteral support and go back to eating a regular diet PO. To prevent
interference with his PO diet he can be on the cyclic feeding from 10pm to 8am so that
he can eat during the day and have the enteral support during the night and wake up in
time to eat PO for breakfast and so on. This means that he will have 50 mL of fluid
delivered to him every hour over the course of 10 hours. Therefore, he will get the 1000
kcal along with about 42g protein and 350 mL of fluid while on the TwoCal HN formula.
The remaining nutritional needs will be made up for in his diet PO. One note to make is
that the patient should receive vitamin/mineral supplementation if necessary to make up
for what is not getting from the 500 mL of enteral feeding at night. Finally, he should
have snacks recommended to him along with his preferences being taken into account
(2 pts) Monitoring plan
A 3-day calorie count should be ordered to make sure that he is meeting his needs
and that he is making up for the energy he is not receiving from the night cyclic
feedings. Again, his vitamin and mineral intake from the PO diet should be taken into
account to make sure he is meeting the RDA requirements. His tolerance to the new
diet order should be monitored to see if the volume of enteral support should be
increased or decreased. Furthermore, the patient should be checked for N/V, diarrhea,
constipation, and abdominal pain/distention to gauge his tolerance. After Mr.G is
receiving 50-75% of his needs from PO then the enteral support can be discontinued.

NUT 116 Bl Enteral Nutrition Support Slides 21-24, 59, 62-65

ADIME Note Calculation Sheet

Jevity 1.2 Cal (Energy, Protein, Fluid)

Jevity 1.2 60 mL/hr

24 hr x 60 mL/hr X 1.2 kcal/mL = 1728 kcal

24 hr x 60 mL/hr x 1 L/1000 mL x 55 g Pro/L = 79.92 g Pro ~ 80g Pro

24 hr x 60 mL/hr = 1440 mL
0.807 x 1440 mL = 1162.08 mL fluid ~ 1162 mL fluid

NUT 116Bl Enteral Support Slides 21-24, 59

Anthropometrics

IBW = 106 # + 6#(10 in) = 166#/2.2# ~ 75.5 kg

IBW% = 165#/166# x 100 = 99% PR pg. 2

Wt loss % = 5kg/75kg x 100 ~ 6.7% Severe Wt loss PR pg. 2

BMI = 70kg/(70 in x 2.54cm/100cm)^2 = 70kg/(1.778)^2 = 70kg/3.161284 ~ 22

Normal PR pg. 1

Estimated Nutrient Needs based on 70 kg wt

a) Energy

(10 x 70 kg) + (6.25 x 177.8 cm) - (5 x 32) + 5

700 + 1111.25 - 160 + 5
1656.25

1656.25 x 1.1 x 1.0 = 1821.875

1656.25 x 1.1 x 1.5 = 2732.8125

~1822-2733 kcal

PR pg 3,5

b) Protein

70 kg x 1.5 g/kg = 105g

70 kg x 2.0 g/kg = 140g

105-140 g Pro/d

PR pg 5
c) Fluid
1822 kcal x 1 mL fluid/kcal = 1822 mL
2733 kcal x 1 mL fluid/kcal = 2733 mL

1822-2733 mL fluid minimum per day

PR pg 6

New Diet Rx

a) Energy

Picked 2700 kcal from range of 1822-2733 kcal

Picked TwoCal HN for formula
2700 kcal/(2 kcal/mL) = 1350 mL/24 hr = 56.25 > 55 mL/hr to meet needs

55 mL/hr x 24 hr x 2 kcal/mL = 2640 kcal

b) Protein
55 mL/hr x 24 hr x 1L/1000mL x 83.5 g Pro = 110.22 ~ 110 g Pro/d

c) Fluid

55 mL x 24 hr x 70% = 924 mL fluid

Picked 1900 mL fluid from range of 1822-2733 mL fluid

1900mL - 924mL = 976 mL/4 = 244mL > 240 mL X4 or Q6
Total Fluid = (4 x 240mL) + 924mL = 1884 mL per day