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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.
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.
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.
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.
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.
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.
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)
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)
PG pg. 6
8. Calculate the energy, protein, and fluid provided by the current TF regimen.
Show your work
a. Energy: (2 pt)
b. Protein: (2 pt)
c. Fluid: (2 pt)
9. You calculate Mr. Gs nitrogen balance at day 10, using the formula and values given
below.
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
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.
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.
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)
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