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Case Study 2

Emily Boward, Erica Dail, Taylor Horne, and Sarah Vacher

1. Describe how burn wounds are classified. Identify and describe Mr. Angelos burn
injuries.
Burn wounds are classified in four stages, the first stage being a lesser wound and the
fourth stage being a greater wound1. A first-degree burn only affects the epidermis and reaches
0.01 inches in depth1. A second-degree burn reaches below the epidermis to the dermis, at 0.02
inches1. A third-degree burn penetrates the dermis and meets the subcutaneous tissue at 0.035
inches1. Finally, a fourth-degree burn affects all of the above layers and reaches to the muscle, at
0.04 inches deep1.
Mr. Angelos burn injuries cover 40% of his total body surface area. Burns cover his
entire face and lower extremities. Blistering is present on genitalia. Partial thickness burns cover
his lower back, buttocks, abdomen, and bilateral upper extremities. Second-degree burns are

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found on most of the upper and lower extremities, while first degree burns are found near the
umbilicus. Overall, the skin exhibits blisters, dryness, and poor skin turgor.

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2. Explain the rule of nines used in assessment of burn injury.

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The rule of nines provides a tool with which to assess how much total body surface area
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(TBSA) of a patient has been burned2. Of TBSA, the head and neck comprise 9%, each arm
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contributes 9%, the thorax makes up 32%, each leg makes up 18%, and the perineum makes up
1%2. Each of these categories can be further divided to represent the posterior and anterior
portions, in order to calculate greater accuracy2. The rule of nines has slightly different
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approximations for children than for adults2. When using the rule of nines for calculating fluid
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requirements, only second-degree burns or worse should be accounted for2.


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3. Mr. Angelos fluid resuscitation order was: LR @ 610 mL/hr x first 8 hours and
decrease to 305 mL/hr x 16 hours. What is the primary goal of fluid resuscitation?
Briefly explain the Parkland formula. What common intravenous fluid is used in burn
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patients for fluid resuscitation? What are the components of this solution?
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Fluid resuscitation is a critical component of treating burn injuries and is the focus of the
first 24 to 48 hours of treatment1. The primary goal of fluid resuscitation is to achieve adequate
tissue perfusion, in order to prevent tissue death and maintain sufficient circulatory volume1.
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Much of the water is lost through evaporation from the wound, resulting in greater fluid needs
for burns with greater TBSA1.
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The Parkland formula can be used to estimate a patients needs for fluid resuscitation,
basing the calculated amount on a patients body weight, age, and % TBSA of the burn2. Of the
calculated amount of fluids needed per day, half of fluid is given in the first 8 hours, as
prescribed in Mr. Angelos fluid resuscitation order, and the rest is administered over the next 16
hours2. However, the Parkland formula is just a place to start2. Urine output can be used to assess
adequate fluid provision and adjust the amount as needed1.
Three common intravenous fluids used in fluid resuscitation for burn patients include
isotonic crystalloids, hypertonic solutions and colloids3. Isotonic crystalloids are the most
commonly used and available solutions, and are found at the cheapest price3. Crystalloids are a
solution of sterile water with added electrolytes4. Common solutions include normal saline and
Lactated Ringers (LR) 3. LR is similar to normal saline, except with lower Na+ and Cl- levels,

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small amounts of K+ and Ca++, and the presence of lactate4. Mr. Angelo is on Lactated Ringers
solution, which matches most closely with plasma contents4. Hypertonic solutions contain more
sodium, such as 250 mEq/L, and have been found to adequately resuscitate patients using a
lower total fluid volume3. However, these solutions have possible side effects such as
hypernatremia and renal failure, and thus if used, must be closely monitored3. Colloids seek to
counter the effects of protein leakage by providing protein in the fluid resuscitation solution, but
are otherwise similar to crystalloids4.

5. Burns are often described as one of the most metabolically stressful injuries. Discuss the
effects of a burn on metabolism and how this will affect nutritional requirements.
The bodys response to burns results in hypermetabolism1. Burns have the capacity to
increase energy requirements up to double of a patients resting energy expenditure, but usually
by at least 20 or 30%1. Burns are also accompanied by infection or stress from surgery; if this is
the case, additional calories are required to maintain weight status and promote healing1. Weight

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loss often occurs with burn patients due to a lack of caloric intake1. It is recommended that a

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patient should not lose more than 10% of the their UBW during the healing process1.

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Carbohydrate needs increase significantly and the liver engages in up to 200% of normal glucose

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synthesis1. Protein losses are almost inevitable due to increased use of protein in wound healing

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and gluconeogenesis, as well as increased nitrogen losses in the urine1. Recent research suggests
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a diet high in protein from burn patients, aiming for 20-25% of calories from protein1. The goal
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is to maintain a positive nitrogen balance1. Increased fat metabolism results in greater amounts of
ketones in the blood and synthesis of fatty acids and triglycerides in the liver1.
In addition to increased energy needs, fluid needs also increase dramatically1. Especially
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in the first 48 hours of treatment, fluid needs must be carefully formulated, provided, and
monitored. Lastly, specific vitamin and mineral supplementation is encouraged1. Doses of 500
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mg b.i.d. Vitamin C are encouraged for increased collagen synthesis and aid in immune
function1. For Vitamin A, 500 units per 1,000 calories are encouraged to support immunity and
the rebuilding of the epithelium1. At different points in the healing process, sodium and
potassium may require supplementation and monitoring1. In patients with a burn of more than
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30% TBSA, calcium may require supplementation, related to deficiency in prealbumin or


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physical inactivity1. Deficiency of phosphate is also a concern for burn patients, when fluid
resuscitation has the ability to mimic the effects of refeeding syndrome on dilution of the blood1.
Magnesium and zinc are also involved in wound healing, metabolism, and protein synthesis and
may be required in increased amounts1.
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6. List all medications that Mr. Angelo is receiving. Identify the action of each medication
and any drug nutrient interactions that you should monitor.
Table 1, shown below, lists each medication that Mr. Angelo is receiving, describes the
drugs action in the body, and identifies any possible drug nutrient interactions5.

Table 1.
Medication Drug Action Drug Nutrient Interactions to
Monitor

Ascorbic Acid 500mg every 12 Vitamin, Antiscurvy Increases Fe absorption, monitor for
hours Fe toxicity

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Chlorhexidine 0.12% oral Topical antispetic
solution 15 mL every 12 hours

Famotidine tablet 20mg every Antiulcer, Anti Hepatic Function, Vitamin B12 with
12 hours GERD, LT use
Antisecretory

Heparin injection 5,000 units Anticoagulant Baseline and periodic APTT,


every 8 hrs platelet count, CBC, Fecal occult
blood, K

Insulin regular injection every 6 Antidiabetic, Serum glucose, Hb A1c, Urine


hours Hypoglycemic ketones, CHO intake

Multivitamin tablet 1 tab daily Vitamin

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Zinc sulfate 220mg daily Mineral Supplement Not compatible with TF (administer

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1 hr before or 2 hrs after)

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Methadone 5mg every 8 hrs Analgesic, Narcotic, Use grapefruit with caution
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Oxandralone 10mg every 12 hrs Antiwasting, Requires adequate Cal and Pro
Anabolic Steroid intake for anabolic effect. Monitor
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glucose in diabetics, hepatic


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function, Hb/HCT with high dose,


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Wt. and Ca.

Senna tablet 8.6mg daily Laxative, Simulant Electrolyte balance, fiber and fluid
intake
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Docusate oral liquid 100mg Stool Softener, Electrolyte balance, fluid status and
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every 12 hours Laxative fiber intake

Silver sulfadiazine 1% cream Topical antibiotic


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topical solution daily


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Acetaminophen 650mg oral Analgesic, Monitor for allergic reaction due to


every 4 hrs prn Antipyretic pt. allergy to drug. Intake should not
*Note pt. has Tylenol allergy exceed 2g/day due to chronic
and should not be taking this alcohol intake.
medication Caffeine increases absorption and
drug effect. Vitamin C intake

Midazolam HCl (versed) 100mg Anesthesia adjunct, Caution with grapefruit, herbal
in sodium chloride 0.9% 100mg Sedative sedatives and stimulants, and
IV infusion, initiate infusion at echinacea, CBC and hepatic and
1mg/hr renal function

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Hydromorphone (Dilaudid) Analgesic, Fluid status for dehydration. Do not
injection 0.5-1mg, intravenous Antitussive, use SR beads in NG tube.
every 3 hours as needed Narcotic, Opioid

Fentanyl (Sublimaze) injection Analgesic, Narcotic, Fluid status, electrolyte balance for
50-100mcg, intravenous every Opioid dehydration
15 minutes as needed

Propofol (Diprivan) 10mg/mL Anesthesia, TG, lipid panel, serum turbidity,


premix infusion, start at Sedative vital signs. Take into account when
25mcg/kg/min, intravenous ordering TF.
continuous

Thiamine 100mg x 3 days B Complex Increased thiamine req. with

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Vitamin, Vitamin increased CHO intake

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B1, Antiberiberi

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Folate 1mg x 3days B Complex Folate metabolism inhibited with
Vitamin, deficiency of Vit B12, Vit C or Fe,

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7. Using evidence-based guidelines, describe the potential benefits of early enteral
nutrition in burn patients.
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According to the evidence analysis library early enteral nutrition (delivered within 24-48
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hours of time of injury or initial procedure) may potentially decrease mortality, length of stay,
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and incidence of infectious complications6. There is currently inconsistent evidence supporting


the conclusion that early enteral nutrition will decrease mortality and length of stay6. The
evidence analysis library conclusion was stated as inconsistent and given a Grade II rating for
early enteral nutrition effects on both mortality and length of stay6. More research is needed to
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determine a conclusive outcome. However, there is good evidence supporting the conclusion that
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early enteral nutrition will decrease the incidence of infectious complications in fluid resuscitated
critically-ill adult patients6. This conclusion was given a Grade I rating6.

8. What are common criteria used to assess readiness for the initiation of enteral nutrition
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in burn patients?
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According to the ASPEN Guidelines, the main criteria used to assess readiness for the
initiation of enteral nutrition in burn patients are hemodynamic stability. ASPEN Guideline A5
states: In the setting of hemodynamic compromise (patients requiring significant hemodynamic
support including high dose catecholamine agents, alone or in combination with large volume
fluid or blood product resuscitation to maintain cellular perfusion) EN should be withheld until
the patient is fully resuscitated and/or stable (Grade: E)7.
Bowel sounds do not need to be considered when assessing readiness for EN initiation as
stated by ASPEN Guideline A6: In the ICU patient population, neither the presence nor absence
of bowel sounds nor evidence of passage of flatus or stool is required for initiation of enteral
feeding (Grade: B)7. This is due to the fact that bowel sounds only indicate contractility and not
absorption ability and mucosal function.

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9. What are the specialized nutrient recommendations for the enteral nutrition formula
administered to burn patients per ASPEN/SCCM guidelines?
According to the ASPEN guidelines listed below burn patients should be administered
immune-modulating enteral formulas7. Supplements of antioxidants and trace minerals as
well as glutamine should be provided to the patient if the immune-modulating formula does
not already contain these agents7. Lastly, soluble fiber may be beneficial for certain cases7.
ASPEN Guideline E1: Immune-modulating enteral formulations (supplemented with
agents such as arginine, glutamine, nucleic acid, omega-3 fatty acids, and antioxidants)
should be used for the appropriate population (major elective surgery, trauma, burns, head
and neck cancer, and critically ill patients on mechanical ventilator), caution in patients with
severe sepsis. (For surgical ICU patients, Grade: A; for medical ICU patients, Grade: B) ICU
patients not meeting criteria for immune modulating formulations should receive standard
enteral formulations7.

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ASPEN Guideline F2: A combination of antioxidant vitamins and trace minerals

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(specifically including selenium) should be provided to all critically-ill patients receiving

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specialized nutrition therapy (Grade: B)7.

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ASPEN Guideline F3: The addition of enteral glutamine to an EN regimen (not already

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containing supplemental glutamine) should be considered in burn, trauma, and mixed ICU
patients (Grade: B) 7.
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ASPEN Guideline F4: Soluble fiber may be beneficial for the fully resuscitated,
hemodynamically stable critically-ill patient receiving EN who develops diarrhea. Insoluble
fiber should be avoided in all critically-ill patients. Both soluble and insoluble fiber should be
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avoided in patients at high risk for bowel ischemia or severe dysmotility (Grade: C) 7.
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ASPEN Guideline E3: To receive optimal therapeutic benefit from the immune modulating
formulations, at least 50-65% of goal energy requirements should be delivered. (Grade: C) 7.
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10. What additional micronutrients will need supplementation in burn therapy? What
dosages are recommended?
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Vitamin C supplementation of 500 mg b.i.d. is encouraged to promote increased collagen


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synthesis and aid in immune function1. For Vitamin A, 500 units per 1,000 calories is
recommended to support immunity and the rebuilding of the epithelium1. In patients with a burn
of more than 30% TBSA, calcium may require supplementation, related to deficiency in
prealbumin or physical inactivity1. In this case, the dosage of calcium supplementation should be
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determined on an individual basis. Deficiency of phosphate is also a concern for burn patients,
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when fluid resuscitation has the ability to mimic the effects of refeeding syndrome on dilution of
the blood1. Supplementation dosage should be based on serum phosphate levels. Magnesium and
zinc are also involved in wound healing, metabolism, and protein synthesis and may be required
in increased amounts1. If zinc supplementation is necessary a dosage of 220 mg of zinc sulfate
should be administered1.

11. Using Mr. Angelos height and admit weight, calculate IBW, %IBW, BMI and BSA.
IBW = 106 + (6 x 12) = 178# ~ 80.7kg
%IBW = 71.2kg / 80.7kg = 88.22%
BMI = 71.2 / 1.82882 = 21.2
BSA = 1.923 m2(8)

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12. Energy requirements can be estimated using a variety of equations. THe Xie and
Zawacki are frequently used. Estimate his energy needs using these. How many kcal/day?
Pt 72 inches = 1.83 meters
Zawacki equation = 1440 kcal/m2/day
Zawacki - 1440kcal * (1.83 *1.83) = 4,822 kcal/day
Xie equation: EEE = (1000 kcal/m2/day) + (25 x BSAB)
EEE = (1000 kcal/m2/day) + (25 x .4) = (1000kcal * (1.83*1.83)) + 10 = 3,359 kcal/day

13. Determine his protein requirements and provide rationale.


2.5* 71.2 kg = 178 g
We recommend that this pt receive approximately 178 g/day because burn victims have
drastically increased protein needs for wound healing.

15. Mds note indicates that patient is experiencing acute kidney injury. What is this? If

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the patients renal function continues to deteriorate and he needs continuous renal

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replacement therapy, what changes will you make to your current nutritional regimen

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and why?

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Acute kidney injury is a sudden reduction in glomerular filtration rate, and altered ability

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of the kidney to excrete the daily production of metabolic waste1. It typically occurs in
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previously well-functioning kidneys. Causes are generally classified in one of three categories:
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inadequate renal perfusion, diseases within the kindey, or urinary tract obstruction1. Because this
patient is a burn victim, he is most likely experiencing intrinsic diseases within the renal
parenchyma due to acute tubular necrosis.
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If his renal function declines further and he needs CRRT, his estimated protein needs will
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should be 1.5-2.5 g/kg due to increased protein losses1. However because this patient is a burn
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victim, his protein needs are already increased for wound healing, so the CRRT would not
increase as much for him as it would for a non-wounded patient. Energy needs should be
estimated at 30-40 kcal/kg, and a high intake of carbs and fat are needed in order to prevent
protein from being used as a source of energy1. This patient has very high caloric needs currently
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for healing his burns, but as they heal and he is put on CRRT, his caloric intake should be
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reduced to 2,163 kcal/day - 2,884 kcal/day. All fluid above the calculated daily water loss should
be given in a balanced salt solution1. Fluid should replace output from the previous day plus 500
ml1. Potassium should be monitored closely and limited to 30-50 mEq/day in the oliguric phase,
and in the diuretic phase it should replace losses1. Phosphorus should be limited as necessary1.
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16. ID at least 2 of the most pertinent nutritional problems and the corresponding
nutrition diagnoses.
Pt needs more fluids to replace leaching fluid from wound sites: Inadequate fluid intake (NI-3.1)
Pt needs elevated levels of protein for wound healing: Increased nutrient needs (protein) (NI-5.1)

17. Write your PES statement for each nutrition problem.


Inadequate fluid intake (NI-3.1) r/t increased fluid needs AEB dry and blistered mucous
membranes, yellow urine color, poor skin turgor, and oliguria.
Increased nutrient needs (NI-5.1) r/t high protein losses and increased energy expenditure
AEB 40% TBSA burn injuries and decreased prealbumin levels.

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18. The patient is receiving enteral feeding using Impact with Glutamine @ 60 mL/hr.
Determine the energy and protein provided by this prescription. Provide guidelines to
meet the patients calculated needs using the Xie equation.
Impact with Glutamine @ 60 mL/hr
- 1.3 kcal/mL9
- 60 ml/hr x 20 hr/day = 1200 ml/day or 1.2 L/day
- 1.3 kcal/mL x 60 mL/hr = 78 kcal/hr
- 78 kcal/hr x 20 hr/day = 1560 kcal/day
- Protein:
78 g/L9 x 1.2 L = 93.6 = 94 g protein
94 g x 9 g/kcal = 846 kcal from protein

Xie equation10: EEE = (1000 kcal x BSA [m2]11) + (25 x %BSAB) = 3,356 = 1930 kcal/day

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19. By using the information on the intake/output record, determine the energy and

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protein provided during this time period. Compare the energy and protein provided by

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the enteral feeding to your estimation of Mr. Angelos needs.

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According to the patients intake and output record, the current input from enteral

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nutrition is 565 ml/day. Compared to Mr. Angelos estimated needs through Impact with
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Glutamine, he is currently receiving 56.5% of those calculated energy needs:
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565 ml / 1200 ml x 100 = 56.5% of energy provided by Glutamine @ 60 ml/hr. at this time
1560 total kcal x .565 = 881.4 = 880 total kcal currently
846 kcal from protein x .565 = 477.99 = 480 kcal currently from protein
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His intake at this time reflects 880 total kcal/day and 480 kcal/day from protein. The two
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stools indicated in the output record demonstrate there is nutrient absorption and GI functioning
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occurring. The reason for the decreased nutrition at this time could be contributed to the fact that
the patient just became stable. This would mean nutrition support is slowly starting to be
administered and will gradually get up to the total estimated caloric needs over time.
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20. One of the residents on the medical team asks you if he should stop the enteral
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feeding because the patients blood pressure has been unstable. What recommendations
can you make to the patients critical care team regarding tube feeding and hemodynamic
status?
It can sometimes occur with critically ill patients receiving enteral nutrition to develop a
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period of hypotension due to gastrointestinal intolerance12. It has been proven that EN is very
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well tolerated before and after period of low blood pressure12. Once a patients blood pressure
becomes stabilized after being hypotensive, enteral nutrition may reduce injury or extent of small
bowel ischemia, can reduce further gut permeability, a patients overall stress response, septic
morbidity, as well as an occurrence of multi-system organ failure12. There has been clinical
studies as well as animal models that contribute to the evidence which says providing enteral
nutrition after a period of hypotension once the patient is stable and resuscitated is the best
practice to ensure a successful patient recovery12. The recommendation in Mr. Angelos case
would be to temporarily hold off on enteral nutrition until the patients hemodynamic status
becomes stable. Once it does, EN should begin again, as this has shown to be successful after a
bout of hypotension.

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21. List factors that you would monitor to assess the tolerance to and adequacy of nutrition
support.
Actual intake of nutrition support in comparison to prescribed intake, because time can be
lost by a dislodged tube, gastrointestinal intolerance, discontinuation of feeding by medical
procedures or activities such as physical therapy, and feeding tube position problems.
- Distension and comfort in the abdomen
- Daily I/O of fluid
- Edema or dehydration symptoms
- Daily stool output/consistency
- Weight (3x/week)
- Nutritional intake adequacy (2x/week)
- Serum electrolytes, BUN, Cr (2-3x/week)
- Serum glucose, Ca, Mg, P (1x per week)1

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22. What is the best method to assess calorie needs in critically ill patients? What are the

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factors that need to be considered before the test is ordered?

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The best method to assess energy needs in critically ill patients is indirect calorimetry by way of

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calculating a Respiratory Quotient or RQ. This test is able to determine whether a patient is
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currently being overfed (by a score of 1 or higher) or underfed or in ketosis (below .7). Factors
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that need to be taken into consideration include whether or not a patient currently has chest tubes
or is experiencing acidosis, because these two occurrences will cause RQ results to not be
accurate.
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References:

1. Mahan LK, Escott-Stump S, Raymond JL. Krauses Food and the Nutrition Care Process.
13th ed. St. Louis, MI: Elsevier; 2012.

2. UW Health. Fluid resuscitation in the burn patient. University of Wisconsin Hospitals and
Clinics Authority Web site. http://www.uwhealth.org/emergency-room/fluid-resuscitation-in-the-
burn-patient/12697. Published December 17, 2012. Accessed November 12, 2014.

3. Haberal M, Abali AE, Karakayali H. Fluid management in major burn injuries. Indian J Plast
Surgery. 2010;43(Suppl):29-36.

4. Martin GS. An update on intravenous fluids. Medscape Web site.


http://www.medscape.org/viewarticle/503138. Published January 1, 2005. Accessed November

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12, 2014.

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5. Pronsky ZM, Crowe JP SR, Food Medication Interactions. 17th ed. Birchrunville, PA: Food

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Medication Interactions; 2012.

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6. Critical Illness: Initiation of Enteral Nutrition. Evidence Analysis Library. Academy of
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Nutrition and Dietetics.
http://www.andeal.org/topic.cfm?cat=4887&conclusion_statement_id=251760&highlight=criteri
a%20to%20assess%20readiness%20for%20initiation%20of%20enteral%20nutrition%20in%20b
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urn%20patients&home=1. Published 2012. Accessed November 15, 2014.


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7. McClave SA, Martindale RG, Vanek VW, et.al. Guidelines for the Provision and Assessment
of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care
Medicine and American Society for Parenteral and Enteral Nutrition. Journal of Parenteral and
Enteral Nutrition. April 27, 2009;33(3):277-316.
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8. DuBois D, DuBois DF. A Formula to Estimate the Approximate Surface Area if Height and
Weight be Known. Arch Int Med. 1916;17:863-71.

9. Products - IMPACT GLUTAMINE. Nestl Health Science Website.


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http://www.nestlehealthscience.us/products/Pages/IMPACT%C2%AE-GLUTAMINE.aspx.
Published 2013. Accessed November 7, 2014.
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10. Prins, A. Nutritional Management of the Burn Patient. The South African Journal of Clinical
Nutrition. 2009; 22(1): 09-15.

11. DuBois D, DuBois DF. A Formula to Estimate the Approximate Surface Area if Height and
Weight be Known. Arch Int Med. 1916;17:863-71.

12. McClave SM, Chang WK. Feeding the Hypotensive Patient: Does Enteral Feeding
Precipitate or Protect Against Ischemic Bowel? Nutr Clin Pract. 2003; 18(4): 279-84.

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