Caroline Mooney

KNH 413
Case Study #4
4/14/2015
Case Questions
1. What is the Glasgow Coma Scale (GCS)?
The Glasgow coma scale is the most common scoring system used to describe the
level of consciousness in a person following a traumatic brain injury. Basically, it is used
to help gauge the severity of an acute brain injury. The GCS is a reliable and objective
way of recording the initial and subsequent level of consciousness in a person after a
brain injury. It is used by trained staff at the site of an injury like a car crash or sports
injury and in the emergency department and intensive care unit. Every brain injury is
different, but generally, brain injuries are classified as serve, moderate, and mild. Serve
is a score of 3-8 and you cannot score lower than three. Moderate is a score of 9-12 and
mild is a score of 13-15. The GCS is usually not used with younger children, especially
those too young to have reliable language skills.
(Mayo Clinic, Brainline)
2. What was Chelseas initial GCS score? Is anything in the physical assessment
consistent with this score? Explain.
Chelseas initial GCS score was a 10. This is consistent with a score of ten because
of the symptoms of obtundation and L-sided hemiparesis, no verbal response,
withdrawal, and moaning when touched. She would be classified as a moderate brain
injury.
3. Define the following terms found in the admitting history and physical:
a. Intensivist:
In intensivist is a medical specialist in critical care medicine. These specialists
have certification in a variety of surgical and medical base specialties
including anesthesia, emergency medicine, internal medicine, pediatrics, and
surgery. Additional training is needed for critical care medicine specialists.
(Wikipedia)
b. L-sided hemiparesis:

L-sided hemiparesis is weakness of the left side of the body. Hemiplegia is the
most severe form, and complete paralysis of this side of the body is possible.
Trauma can often cause hemiparesis.
(Wikipedia)
4. Read the CT scan and MRI report. The CT scan report was very general,
noting density in the frontal lobe. The MRI indicated more localized areas of
edema and blood in the frontal lobe. It also discusses a shearing injury.
a. What causes edema and bleeding in a traumatic brain injury?
Brain edema leading to an expansion of brain volume has a crucial impact on
morbidity and mortality following traumatic brain injury as it increases pressure,
impairs cerebral perfusion and oxygenation, and contributes to additional
ischemic injuries. Bleeding in and around the brain, swelling, and blood clots can
disrupt the oxygen supply to the brain and cause wider damage. Edema is the
bodys response to many types of injury. Swelling can occur in specific locations
or throughout the brain. Swelling can block other fluids from leaving the brain
such as blood making the swelling even worse.
b. What general functions occur in the frontal lobe? How might Chelseas
injury affect her in the long term?
The frontal lobe is the brains largest lobe, so it is very important. The frontal
lobe is responsible for reasoning, planning, parts of speech, movement, emotion,
personality, and problem solving. It consists of a right and left lobe or
hemispheres. The left frontal lobe deals with language abilities while the right
frontal lobe is generally concerned with non-verbal aspects of communication,
such as awareness of emotions in ones facial expressions. The left frontal lobe
damage will affect language, verbal skills and positive emotions, while right
frontal damage will affect non-verbal communication and negative emotions.
If the frontal lobe is damaged it could negatively effect Chelseas life in the
future many different ways. The degree of dysfunction after the brain trauma has
been resolved depends on the abilities of the individual before the TBI, was well
as the extent, location, and nature of the damage. It may affect aspects of
behavior, mood, and personality, during recovery, the family will have to adapt to
what was previously basic human behavior, such as the relationship with oneself

and others. Behavioral problems of people with frontal lobe damage complicate
recovery. She could experience mood swings, depression, hyperactivity and
aggression. Intolerance for frustration and easily provoked aggression are typical.
Brain injuries do not heal easily, and even with todays technology it can be hard
to predict if a person will ever fully recover. (Mayo Clinic, PedMed, Brain Injury
Institute)
5. What factors place the patient with traumatic brain injury at nutritional
risk?
A healthy diet during the recovery from a brain injury is highly beneficial. When
someone sustains a brain injury, it is necessary to eat enough nutritional calories to
help the brain function efficiently. It is highly recommended that fresh vegetables,
fruits, fish, meats, and grains are superior to processed foods and build the immune
system. In addition, there are a few suggested supplements may help complement
and enhance your nutritional intake. A multivitamin can supply the basic vitamins
and supplement that your diet may be lacking. Omega-3 fatty acids counteract free
radicals that cause oxidative damage to brain cells and may help improve nerve signal
transmission at synapses. Probiotics are a bacteria that helps maintain a healthy
intestine and aids in digestion. Antioxidants which include vitamins C, E, and beta
carotene counteract oxidative damage caused by certain foods, and stress caused by
brain injury. Brain Vitale is a product that combines two beneficial brain nutrients
phosphatidyl serine and acetyle carnitine, which help repair neurons. Phosphatidyl
serine aids in the proper release and reception of neurotransmitters in the brain help
with memory. Acetyle L-carnitine plays a key role in fatty acid oxidation and is used
to improve memory. Coenzyme Q10 is a natural antioxidant that is necessary for the
basic functioning of cells. B vitamins boost metabolism and effect brain and nervous
system functioning. And lastly, glycerphosphocholine helps to sharpen alertness,
reasoning, information processing, and other types of mental performance. (brainline)
6. Chelseas height is 132 cm, and her weight on admission is 27.7 kg. At age 9
years of age, what is the most appropriate method to evaluate her height and
weight? Assess her height and weight.

The most appropriate method to evaluate her height and weight would be
to use CDC height and weight charts. Her height and weight are within the normal
range. She was 50th percentile for weight for her age and 75th percentile in height
for her age.
7. What method should you use to determine Chelseas energy and protein
requirements? After specifying your method, determine her energy and
protein needs.
You should use the Harris-Benedict formula, which is good when dealing
with patients who have suffered an injury or trauma.
Energy Needs:
655.1+9.6(27.7)+1.9(132)-4.7(9)=~1,100=1,200 kcal/day
1,100x1.4=1,500-1,600 kcal/day
Protein Needs:
1.5-2.0 grams/kg of body weight
1.5x27.7kg=~42 grams protein
2.0x27.7kg=~56 grams protein
8. Chelsea was to receive a goal rate of Nutren Jr with fiber @ 85 cc/hour. How
much protein would this provide? Show your calculations. Does it meet her
needs?
The Nutren Jr with fiber provides 1 kcal per mL, and 12% protein. This amount
would give Chelsea 85kcal/hour. For an entire day, this means that Chelsea would be
getting about 2,040 kcal, and about 245 kcal of protein a day. This calculation shows that
Chelseas needs are being met.
(1 kcal/cc x 85cc=85 kcal)
(85 x 24 hr=2,040 kcal)
(2,040 x .12=245 kcal)
9. Using patient care summary sheet, answer the following:
a. What was the total volume of feeding she received on June 5?
On June 5th Chelsea received 1,588 cc of fluid. (85 x 17)+50
b. What was the nutritional value of her feeding for that day? Calculate the
total energy protein.
1,580x.12=~190 kcal from protein

c. What percentage of her needs was met?

77% of her calorie needs were met (1580/2040)x100, and 77% of her calories
from protein were met (190/245)x100.
d. There is a note on the evening shift that the feeding was held for residual.
What does that mean?
This means that the food or liquid from the previous feeding was left in her
stomach, causing higher levels of material from feedings earlier that day.
e. What is aspiration? What are the potential consequences?
Aspiration is foreign matter into the lung. Those at risk for aspiration include:
those who cant swallow normally, those who are sedated, and those with an
endotracheal tube. Consequences of aspiration include pneumonia or even
death. (Nelms pp. 91).
f. What is the usual procedure for handling a high gastric residual? How do
you think Chelseas situation was handled?
The usual procedure for handling a high gastric residual includes: monitoring
for extra gastric volume every 4-6 hours, residual volume should be checked
before nutrients are added, the patient should be elevated, and checking tube
placement is also very important. I think Chelseas situation was handled
correctly. Once her residual was clear, her feedings began again, which was
the correct thing to do.
g. What other information would you assess on the daily flow sheet to
determine her tolerance to the enteral feeding?
Other information that I would assess on the daily flow sheet to determine her
tolerance to the enteral feeding would be weight gain or loss, her appetite,
bowel movements, and urine.
h. Look at the traditional information on the patient care summary sheet.
Are there any factors of concern? Explain.
The only concern I have when looking at the information on the patient care
summary sheet is that she hasnt been producing much output, which should
be looked into further, and may be of concern.
10. Evaluate Chelseas laboratory data. Note any changes from admission day
labs to June 3. Are any changes of nutritional concern?
There are a few changes from admission day to June 3rd that are of
concern. Her albumin decreased, her sodium decreased, her potassium
decreased, her chloride increased, and her creatinine was low.

11. On June 6, a 24-hour urine sample was collected for nitrogen balance. On
this day, she received 1650 cc of Nutren Jr. Her total nitrogen output was 14
grams.
a. Calculate her nitrogen balance from this information. Show all your
calculations.
Nitrogen balance=protein intake/6.25-urine urea nitrogen-4(6.25=1g)
50 grams prptein in1,650 cc Nutren Jr
~50 grams protein/6.25-14=1 gram nitrogen
50/6.25-14-4=7.92-14-4=-10.08grams
b. How would you assess this information? Explain your response in the
context of her hypermetabolism.
A negative nitrogen balance is very common for someone who just went
through a serious injury, or someone who is going through a period of fasting.
Negative nitrogen balances can also be used as an evaluation for malnutrition.
Hypermetabolism is characterized by extreme weight loss, and typically occurs
after injury to the body. Elevation of metabolic rate following a brain injury has
been reported with estimates of 32-200% above normal values.
c. Are there any factors that may affect the accuracy of this test?
There are many factors that can either make nitrogen balance results positive or
negative. Periods of growth, pregnancy, and tissue repair all can cause a nitrogen
balance to be positive while fevers, burns, wasting diseases, and other injuries can
cause nitrogen balances to be negative.
d. The intern taking care of Chelsea pages you when she reads your note
regarding her negative nitrogen balance. He asks whether he should
change the enteral formula to one higher in nitrogen. Explain the results
in the context of the metabolic stress response.
I do not think that Chelseas enteral formula should be changed to one that is
higher in nitrogen. Negative nitrogen balances can be very common in those who
have just been through a serious injury or have a problem with malnutrition or
wasting. These values can also last for a couple weeks. Chelsea has experienced
both of these symptoms in some aspects so changing her formula would likely not
make much difference on her nitrogen balance values.

12. Chelsea has worked with occupational therapy, speech therapy, and physical
therapy. Summarize the training that each of these professionals receives and
what their role might be for Chelseas rehabilitation.
Occupational Therapist: The first step to becoming an Occupational Therapist is
to receive your Bachelors degree. Some common majors chosen include sociology,
psychology, and anthropology. Next you must earn your masters degree; most
degrees here include: anatomy, patient care, and assistive technology. Fieldwork is
usually done in nursing homes, rehab centers, and schools. Next you must get your
license in your state. In order to receive your license you must: have graduated from
an accredited occupational therapy program, have completed necessary fieldwork,
and passed the NBCOT exam. You will then receive your Occupational Therapist
Registered Credential. The expected role of an Occupational Therapist in Chelseas
rehabilitation would be to assist her in independence of all aspects of her daily life.
This would include daily living, productive activities, leisure activities, and help
guide the process of OT. Treatment sessions usually focus on engaging individuals in
meaningful activities to help them in achieving their goals to reach independence.
This will also help Chelsea a lot when she is transitioning back to her daily school
life.
Speech Therapist: The first step to becoming a Speech Therapist is to complete
your bachelors degree with coursework in communications and biological sciences.
Next you must receive your Masters degree from an accredited program usually
completed in 2 or 3 years. This provides training through coursework, research, and
clinical experiences. Courses usually include anatomy, physiology, phonetics,
linguistics, and phonology. Students must then complete 25-40 hours of on-site,
supervised training to complete their degree. You must then get your licensure after
completing an accredited ASHA. Additional hours must be completed to maintain
your licensure. The expected role of a Speech Therapist in Chelseas rehabilitation
would be to help her with getting general responses to sensory stimulation and
teaching family members to interact with her at the beginning stages of her recovery.
Once she becomes more aware the Speech Therapist must then help her maintain her
attention for simple activities, reduce her confusions, and help get her oriented with

where she is, what happened, what day it is etc. Later on in her recovery the Speech
Therapist will: help her find ways to improve her memory, learn problem-solving
strategies, work on social skills, and improve self-monitoring. Towards the end of her
treatment, the Speech Therapist can help her get back to her school life.
Physical Therapist: In order to become a Physical Therapist you must first get a
bachelors degree in a number of area including biology, anatomy, pre-physical
therapy and more. You then need to get a graduate degree. Doctoral programs and
masters programs are both available. Doctor of Physical Therapy programs train
students in the procedures of diagnosis and treatment. Clinical clerkships in DPT
programs place students in healthcare facilities under the supervision of licensed
physical therapists. Next, most states typically require a passing score on the National
Physical Therapy Examination as part of getting your license. Continuing education
must then be done to retain your license. The role of a Physical Therapist in Chelseas
rehabilitation will be to help her in movement to help strengthen her physical
abilities. This will help relieve pain through exercise. They will also help her with
motility and recommend devices to help her move independently.
(Education Required to Become a Physical Therapist) (How To Obtain Your
Occupational Therapy Degree) (Speech Therapy Training) (Traumatic Brain Injury)
(Speech Disorders)
13. The speech pathologist saw Chelsea for swallowing evaluation on hospital
day 10. (see p. 395.)
a. What is a video fluoroscopy?
Video fluoroscopy is an imaging technique that uses X-rays to obtain realtime moving images of the inside of an object. This allows the physician
to see the internal structure and function of a patient, so that the motion of
swallowing can be watched.
(Wikipedia)
b. What factors were noted that support the need for enteral feeding at
this time?

It is evident that Chelsea needs to continue on her enteral feeding because in

the report it stated that Chelsea choked after 5-7 ice chips, and she showed
significant signs of fatigue and decreased cooperation after a few swallows.
(Speech-Language Pathology)
14. As Chelseas recovery proceeds, she beings a PO mechanical soft diet. Her
calorie counts are as follows:
(10/14)
oatmeal c
brown sugar 2 T
whole milk 1 c
240 cc Carnation Instant Breakfast (CIB) prepared with 2% milk
mashed potatoes 1 c
gravy 2 T
(10/15)
Cheerios 1 c
whole milk 1 c
240 cc CIB prepared with 2% milk
grilled cheese sandwich (2 slices bread, 1 oz American cheese 1 tsp
margarine)
Jell-O 1 c
240 cc CIB prepared with 2% milk
a. Calculate her intake and average for these two days of calorie counts.

Food Item

Calories (kcal)

Protein (grams)

cup oatmeal

75

2.5g

2 tbsp brown sugar

15

0g

1 cup whole milk

150

8g

240 cc Carnation Instant 320

13g

Breakfast with 2% milk

1 cup Mashed Potatoes

~200

4g

2 tbsp gravy

15

0g

Total

~775

~28

1 cup cheerios

100

3g

1 cup whole milk

150

8g

240 cc CIB with 2% milk 320

13g

2 slices bread

~150

5g

1 oz American cheese

70

5g

1 tsp margarine

35

0g

1 cup jell-o

~80

2g

240 cc CIB with 2% milk 320

13g

Total

~50

~1,200

Average kcals

Average protein

~990

~40

b. What recommendations would you make regarding her enteral feeding?

At this time I would recommend that Chelsea consume an additional 500
calories a day. What she consumed in the 2 days in the chart above shows that she
was not getting nearly enough calories. I would also recommend that Chelsea get
more protein in her diet. Since Chelsea is at a great risk of losing more of her
body weight it is crucial that she gets adequate energy for her recovery. I would
then recommend that she transition from enteral feedings to a normal diet with
soft foods that she is able to swallow.
Resources
Brainline. What Is the Glasgow Coma Scale? (n.d.). Retrieved October 29, 2014.
http://www.brainline.org/content/2010/10/what-is-the-glasgow-coma-scale.html

Brainline. Feed Your Body, Feed Your Brain: Nutritional Tips to Speed Recovery. (n.d.).
Retrieved October 29, 2014.
http://www.brainline.org/content/2010/12/feed-your-body-feed-your-brain-nutritionaltips-to-speed-recovery.html
Brain Injury Institute. Brain Injury. (n.d.).
http://www.braininjuryinstitute.org/Brain-Injury-Types/Frontal-Lobe-Damage.html
Education Required to Become a Physical Therapist. (n.d.). Retrieved October 23, 2014.
Fluoroscopy. (n.d.). Retrieved April 13, 2015, from http://en.wikipedia.org/wiki/Fluoroscopy
Hemiparesis. (n.d.). Retrieved April 13, 2015, from http://en.wikipedia.org/wiki/Hemiparesis
How To Obtain Your Occupational Therapy Degree. (n.d.). Retrieved October 23, 2014, from
http://www.otplan.com/articles
Intensivist. (n.d.). Retrieved April 13, 2015, from http://en.wikipedia.org/wiki/Intensivist
Mayo Clinic. Traumatic brain injury. (n.d.). Retrieved October 29, 2014.
http://www.mayoclinic.org/diseases-conditions/traumatic-brainPediaSure 1.5 Cal. (n.d.). Retrieved October 23, 2014.
Pedmed. Result Filters. (n.d.). Retrieved October 29,
2014.http://www.ncbi.nlm.nih.gov/pubmed/15561417
Result Filters. (n.d.). Retrieved October 23, 2014, from http://www.ncbi.nlm.nih.gov
Signs That a Feeding Tube Is Working. (2010, September 28). Retrieved October 23,
2014.

Speech-Language Pathology. (n.d.). Retrieved October 23, 2014, from

http://www.cincinnatichildrens.org
Speech Therapy Training. (n.d.). Retrieved October 23, 2014, from
http://link.springer.com/chapter/10
Stress. (n.d.). Retrieved October 23, 2014, from http://www.diabetes.org
Traumatic Brain Injury (TBI). (n.d.). Retrieved October 23, 2014, from
http://www.asha.org/public/speech/disorders/TBI/