Case Study: Burn Patient

By Paige ONeil and Trevor Talbot

Demographics
Patient: J.A. Language: English

Age: 65 Education: 11 years

Sex: Male

Race: Caucasian

Marital status: Single

Anthropometrics
Height: 72, 6 ft Temp: 100

Weight: 156.6 lbs, 71.2 kg BP: 140/90

BMI: 21.3- healthy Pulse: 120

IBW: 178 lbs, 81 kg

%IBW: 88%
Hospital Admittance

J.A. was admitted to the hospital after his clothes caught fire during a motor
vehicle accident. He suffered burns to the face, bilateral upper and lower
extremities, scrotum, buttocks, and back. J.A. is unclear about what
happened, as his story changed several times.

Other diagnoses: Diabetes, HTN, GERD

Medical history: Cholecystectomy 30 years ago

Dietary History
-No 24 hour recall was obtained due to the emergency situation

-Does not follow any specific diet

-Stable weight for past 6 months

-Has not been monitoring blood glucose levels for about a year
Social History
-Recently unemployed

-Previously lived alone, but was traveling to move in with parents

-Has smoked one pack per day for over 30 years

-Drinks 2-3 beers every weekday, drinks 1 case on Saturdays and Sundays

-Mother: Anxiety disorder and HTN

-Father: HTN

-Brother: Healthy
 Disease/Condition

Principal problem:

Burn Injury: level 1 trauma with 40% total body surface area (TBSA) burns

Active problems:

Diabetes: Unknown whether type 1 or type 2

Glucose: 211

HTN: 140/90

Respiratory failure: Occasional wheezing/patchy infiltrates on chest x-ray

GERD: Possibly linked to habitual alcohol consumption

 Laboratory Data

Potassium 3.5-5.5 5.9 Cellular tissue damage

Chloride 95-105 115 Indicates dehydration

CO2 23-30 20 Due to smoke inhalation

Creatinine Serum 0.6-1.2 1.26 Kidney function/disease

Glucose 70-110 211 Indicates diabetes

Protein 6-8 4.7 Loss through wounds

Albumin 3.5-5 2.1 Inflammation, shock, malnutrition

Prealbumin 16-35 12 Sepsis and organ dysfunction

 Laboratory Data Contd
AST 0-35 44 Liver damage, may be due to alcohol use

C-Reactive Protein <1 12 Acute Inflammation

WBC 4.8-11.8 18.1 Inflammation

Hemoglobin 14-17 18.7 Need for an increased oxygen supply

Hematocrit 40-54 54.4 Dehydration or decreased oxygen

PH 7.35-7.45 7.31 Acidic state

HCO3 24-28 19.6 Metabolic acidosis

 Discussion of Laboratory Data
Elevated C-reactive protein: from trauma and inflammation
~ 12 xs higher than normal levels
Related to hypoalbumenia: decreased levels of albumin have been shown to be
correlated negatively with CRP levels
more closely associated with inflammation than nutrition status
associated with greater burned body surface area
Elevated WBC count
Threat of infection/sepsis
Decreased bicarbonate and pH
Metabolic acidosis
Hyperkalemia
Related to oliguria, tissue damage, and kidney damage
 Hospital Course

40% TBSA burn: Managed per burn team. Daily dressing changes
continued. Sent to OR for debridement and split thickness skin grafting
Respiratory failure: Intubated for airway protection. Bronchoscopy
performed
Pain: Versed gtt (drops), increase methadone to 10mg every 8 hours.
Dialudid and fentanyl prn (when necessary). Wean Propofol off possibly by
the end of the day of admission: currently at 25ml/hr
Hyperkalemia: Secondary to metabolic, respiratory acidosis. Improving Last
K+5.9. Continue to resuscitate with LR (lactated Ringers solution)
Protein-calorie malnutrition: Advance TF to goal rate per nutrition
Acute kidney injury: Continue fluid resuscitation.
 Nutrient Considerations
Protein needs: 1.5-2g/kg: for wound healing
Protein needs can be as much as 150% of usual protein requirements
Burn patients have a non-functional skin barrier in the affected areas: experience loss
of liquids, minerals, proteins and electrolytes, protein, and micronutrient deficiencies
Burn injuries with >20% of TBSA: energy needs can be as much as 140% of basal energy
requirements
Enteral route of administration: Jejunostomy preferred over gastrostomy
18% failure rate in the gastrostomy from regurgitation
Consideration of using a specialized diabetes enteral formula, intended to aid in improved
glycemic control
The EAL reports that the lack of research at this time does not appear to indicate
the routine use of DM-specific EN formulas
Fluid Needs

Parkland formula (IV used for burn patients) 4ml x TBSA (total burned
surface area) (%) x body weight (kg)

4ml * 40 (%TBSA) * 71.2kg = 11,392 mL/day or 474 mL/hr

Originally receiving 610 mL/hr = 14,640 mL/day

Nutrition Prescription
Original: NPO with EN Impact with glutamine @ 20 ml/hr, advance 20
ml/hr, advance 20 ml/hr every 4 hours to 60 ml/hr. Final goal rate per RD
2,280 kcals/day
New EN prescription: NPO with EN Impact 2 with glutamine @ 20 ml/hr,
advance 20 ml/hr every 4 hours to goal rate of 71 ml/hr.
3,408 kcals/day
Patients with >40% TBSA can lose 25% of preadmission weight in 3
weeks without nutrition support
PES Statement 1

Inadequate energy intake, related to total burn surface area of 40%, as

evidenced by calculated and unmet energy needs at 3,380 kcals

Intervention: Change enteral prescription to provide enough kilocalories

for proper healing

Goal: Maintaining health of the patient and improving the state of his burns
in the most efficient way possible
PES Statement 2

Inadequate protein intake, related to total burn surface area of 40%, as

evidenced by calculated and unmet protein needs at 213g

Intervention: Change enteral prescription to provide enough protein for

proper healing of wounds

Goal: Maintaining health of the patient and improving the state of his burns
in the most efficient way possible
PES Statement 3

Inconsistent carbohydrate intake, related to diagnosis of diabetes, as

evidenced by plasma glucose at 211 mg/dL

Intervention: Nutrition education about diagnosis and the importance of

carbohydrate counting

Goal: Normalize blood sugar levels

 Conclusion and Progression

A burn patient will be in the hospital 1 to 2 days for each

percent of total body surface area burned
40-80 days recovery period expected
Physical therapy, occupational therapy, and mental health
consultations, in addition to nutrition consultation
Notify the family: his parents
Continued lowfat, highprotein, highcarbohydrate, enteral
tube feedings with appropriate caloric content.
Weekly or biweekly assessments of nutritional status
References
Brown, B., Roehl, K., & Betz, M. (2015). Enteral Nutrition Formula Selection: Current Evidence
and Implications for Practice. Nutrition In Clinical Practice, 30(1), 72-85. doi:10.1177/0884533614561791
Burn. (2016). In Helicon (Ed.), The Hutchinson unabridged encyclopedia with atlas and weather
guide. Abington, UK: Helicon. Retrieved from
http://marywood1.marywood.edu:2048/login?url=http://search.credoreference.com/content/entry/heliconhe/burn/0?insti
tutionId=2484
Charney, P., & Malone, A. (2016). ADA pocket guide to nutrition assessment (3rd ed.). Chicago:
American Dietetic Association.
Cleveland Clinic . (2017). Ileal Pouches. Retrieved November 04, 2017, from
https://my.clevelandclinic.org/health/articles/ileal-pouches
Grobler, R. C., Nurs, D., & CliNursSc, D. (2012). Emergency management of the patient with
severe burns in the emergency unit. Professional Nursing Today, 16(3), 37-45.
Ishida, S., Hashimoto, I., Seike, T., Abe, Y., Nakaya, Y., & Nakanishi, H. (2014). Serum
albumin levels correlate with inflammation rather than nutrition supply in burns patients: a retrospective study. The
Journal of Medical Investigation, 61(3.4), 361-368. doi:10.2152/jmi.61.361
Mundi, M. S., Shah, M., & Hurt, R. T. (2016). When Is It Appropriate to Use Glutamine in
Critical Illness?. Nutrition In Clinical Practice, 31(4), 445-450. doi:10.1177/0884533616651318
References
Muzaffer, D., zlem, M., Abdl Kerim, Y., Yaln, B., & Muhitdin, E. (2016). Nutritional
Therapy in Burns. Turkish Journal Of Plastic Surgery, Vol 24, Iss 4, Pp 166-172 (2016), (4), 166.
doi:10.5152/TurkJPlastSurg.2016.2057
Nelms, M. N. (2016). Nutrition therapy and pathophysiology (3rd ed.). Boston, MA: Cengage
learning.
Nutrition MD. (2017). Burns: Nutritional Considerations. Retrieved November 17, 2017, from
http://www.nutritionmd.org/health_care_providers/integumentary/burns_nutrition.html
SKOLNIK, P. L. (2015). POST-ACUTE CARE NUTRITION CHALLENGES IN BURN
INJURY SURVIVORS. Journal Of Nurse Life Care Planning, 15(3), 908-911.
Qing, C. (2017). Invited Review: The molecular biology in wound healing & non-healing
wound. Chinese Journal Of Traumatology, 20189-193.doi:10.1016/j.cjtee.2017.06.001