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Case Questions
I. Understanding the Diagnosis and Pathophysiology
1. Describe how burn wounds are classified. Identify and describe Mr. Angelo’s burn
injuries.
The Burn can be classified by the depth of burn on the scale of range from one to four. The
first stage is reaching the tissue layer of epidermis which about 0.010 inches of skin thickness.
The second stage is reaching the tissue layer of Dermis which about 0.020 inches of Skin
thickness. The third stage is reaching the tissue layer of Subcutaneous tissue which about
0.035 inches of skin thickness. The fourth Stage is reaching the tissue layer of Muscle which
about 0.040 inches of skin thickness.
Mr. Angelo’s burn is involving 40% body surface area, and the burn of his head involving
entire face, signed eyebrows, hair, and facial hair. The Partial thickness burn over lower back,
buttocks, bilateral upper extremities, and Abdomen. The Full thickness circumferential burns
to lower extremities. His upper and lower extremities can be identified as the second stage
burn, and his lower back, buttocks, bilateral upper extremities, and abdomen can be identified
as the first stage burn.
The “Rule of Nines” is one method that can be used to make a rapid estimation of BSA(Body
Surface Area) that has been involved burn injury, and this method divide our body into
portions with a value or derivative of nine. In the Rule of Nines to Estimate Body Surface Area,
there are 9% for entire head, 9% for anterior torse, 9% for upper back, 9% for entire arm,
9% for anterior abdomen, 9% for lower back, 1% for perineum (Male), 9% for Anterior leg,
and 9% for Posterior leg. The adult skin area is composed by 9% of Head and neck, 36% of
torso, 18% of Arms, 36% of legs, and 1% of Perineum.
3. Mr. Angelo’s fluid resuscitation order was: LR @ 610 mL/hr × first 8 hours and
decrease to 305 mL/hr × 16 hours. What is the primary goal of fluid resuscitation?
Briefly explain the Parkland formula. What common intravenous fluid is used in burn
patients for fluid resuscitation? What are the components of this solution?
The initial treatment of the first 24 to 48 hours for thermally injured patients are fluid
resuscitation. The primary goal of fluid resuscitation is preventing burn shock by giving
adequate fluid, maintaining circulatory volume, providing metabolic water, maintaining tissue
perfusion, and preventing the deep burn. Moreover, the volume of fluid needed is based on
the age and weight of the patient and the extent of the injury designated by percentage of
total body surface area (TBSA) burned.
The Parkland formula is common formula to calculate the volume of resuscitation fluid for
patients, and the volume of resuscitation fluid is approximately 2 to 4 mL/kg body weight per
percentage of burn depending on the patient’s physiologic demands or response. Usually,
about half of the calculated volume for the first 24 hours is given during the first 8 hours after
burn injury and the remaining half in the next 16 hours.
The common intravenous fluid which is used in burn patients for fluid resuscitation are Isotonic
Crystalloids, Hypertonic solutions, and Colloids. The Isotonic is composed by Isotonic sodium
chloride solution and lactated Ringer. The Hypertonic solutions is a solution that has a high
combination of both sodium and chloride. The Colloids is used to treat the problem of oedema
which is cause by leakage and accumulation of plasma proteins outside the vascular
compartment.
Contributor, N. (2020, February 20). Parkland formula - fluid resuscitation in burns patients 1:
Using formulas. Retrieved October 22, 2020, from https://www.nursingtimes.net/clinical-
archive/accident-and-emergency/parkland-formula-fluid-resuscitation-in-burns-patients-1-
using-formulas-03-04-2008/
Haberal, M., Sakallioglu Abali, A., & Karakayali, H. (2010, September). Fluid management in
major burn injuries. Retrieved October 22, 2020, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038406/
The inhalation injury is caused by the inhalation of smoke or chemical products of combustion,
and it may be present in the patient who sustained burns and have been in a smoke
environment for prolonged periods of time. Patients who have airway compromise may require
intubation and mechanical ventilation, and patient also have a high risk of dysphagia as the
result of the inhalation injury or prolonged intubation and may require enteral nutrition.
Dries, D., & Endorf, F. (2013, April 19). Inhalation injury: Epidemiology, pathology, treatment
strategies. Retrieved October 22, 2020, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3653783/
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.
A burn patient has greatly accelerated metabolism and needs increased energy,
carbohydrates, proteins, fats, minerals, vitamins, and antioxidants to help our body to heal
and prevent detrimental sequelae. The increased energy needs of the burn patient vary
according to the size of the burn, with severely burned patients often approaching twice their
predicted energy expenditure, and the burn size also is important to measured energy
expenditure follow by age. Therefore, increasing energy requirements about 20% to 30% ins
important to account for energy expenditure associated with wound care and physical therapy.
In addition, the intake of protein also needs to increase since losses through urine and
wounds, increased use in gluconeogenesis, and wound healing, and patient need 20% to 25%
of total calories as protein of high biologic value.
6. List all medications that Mr. Angelo is receiving. Identify the action of each
medication and any drug–nutrient interactions that you should monitor.
https://medlineplus.gov/?_ga=2.250571462.1964553455.1603159838-1023368000.1601177203
Base on the book “ Krause’s Food & The Nutrition Care Process”, Author mention that Enteral
nutrition should be considered for the patients who are unable to eat or cannot achieve
adequate intake by food alone, and the achievement of enteral access and provision of a
sufficient volume of enteral nutrients early in the hospital course of a critically ill burn patient
affords an opportunity to improve the outcome of that patient. Enteral feeding also can
provide a conduit for the delivery of immune stimulants and serves as effective prophylaxis
against stress-induced gastropathy and GI hemorrhage. It also can aid delivery of enteral
nutrients while reducing risk of aspiration.
8. What are the common criteria used to assess readiness for the initiation of enteral
nutrition in burn patients?
Base on the research article “Guidelines for the Provision and Assessment of Nutrition Support
Therapy in the Adult Critically Ill Patient”
The Common Criteria used to assess readiness for the initiation of enteral nutrition in burn
patients
McClave, S., Martindale, R., Vanek, V., McCarthy, M., Roberts, P., Taylor, B., . . . Cresci, G.
(2009, April 27). Guidelines for the Provision and Assessment of Nutrition Support
Therapy in the Adult Critically Ill Patient:. Retrieved October 22, 2020, from
https://onlinelibrary.wiley.com/doi/full/10.1177/0148607109335234
9. What are the specialized nutrient recommendations for the enteral nutrition formula
administered to burn and trauma patients per ASPEN/SCCM guidelines?
Base on the research article “Guidelines for the Provision and Assessment of Nutrition Support
Therapy in the Adult Critically Ill Patient”, the author mention ASPEN guidelines that (have
specialized nutrient recommendations for the enteral nutrition formula administered to burn
and trauma patients) are using immune0modulating enteral formulation, and giving a
combination of antioxidant vitamins and trace minerals.
The ASPEN guideline E3: To receive optimal therapeutic benefit from the immune ‐modulating
formulations, at least 50%‐65% of goal energy requirements should be delivered.
The ASPEN guideline F2: A combination of antioxidant vitamins and trace minerals (specifically
including selenium) should be provided to all critically ill patients receiving specialized nutrition
therapy.
The ASPEN guideline F3: The addition of enteral glutamine to an EN regimen should be
considered in burn, trauma, and mixed ICU patients.
McClave, S., Martindale, R., Vanek, V., McCarthy, M., Roberts, P., Taylor, B., . . . Cresci, G.
(2009, April 27). Guidelines for the Provision and Assessment of Nutrition Support
Therapy in the Adult Critically Ill Patient:. Retrieved October 22, 2020, from
https://onlinelibrary.wiley.com/doi/full/10.1177/0148607109335234
What additional micronutrients will need supplementation in burn therapy? What
dosages are recommended?
Glutamine:
0.3–0.5 g/kg/day for 10-g doses via feeding tube 2–4 × daily
Zinc:
Selenium:
≥20% TBSA full thickness and intubated or ≥30% TBSA: 1000 μg/day parenterally × 14
days and then 200 μg twice daily by mouth or feeding tube
Vitamin C:
≥20% TBSA full thickness or ≥30% TBSA: 500 mg/day twice daily by mouth or feeding
tube
Vitamin E:
400 units twice daily by mouth or feeding tube
10. Using Mr. Angelo’s height and admit weight, calculate IBW, %IBW, BMI, and BSA.
BMI= 71.2kg/1.83m^2=21.3kg/m2
IBW=106lb+6*(12) =178lb
%IBW=(157/178 )* 100%=88.2%
11. Energy requirements can be estimated using a variety of equations. The Xie and
Zawacki equations are frequently used. Estimate Mr. Angelo’s energy needs using
these equations. How many kcal/kg does he require based on these equations?
12. Determine Mr. Angelo’s protein requirements. Provide the rationale for your
estimate.
IBW=178lb = 81kg
2 x 81 = 162g protein/kg
For the burn patient, we want to promote wound healing, therefore this range for protein
requirement is rational.
13. The MD’s progress note indicates that the patient is experiencing acute kidney
injury. What is this? If the patient’s renal function continues to deteriorate and he
needs continuous renal replacement therapy, what changes will you make to your
current nutritional regimen and why?
The Acute Kidney injury is a disorder which characterized by an sudden decline in glomerular
filtration rate (amount of filtrate per unit in the nephrons), and altered ability of the kidney to
excrete the daily production of metabolic waste. Acute Kidney occur in association with oliguria
or normal urine flow, but it typically occurs in previously healthy kidneys, and the duration of
AKI varies from a few days to several weeks.
If the patient’s need continuous renal replacement therapy, I firstly will suggest his estimated
protein needs increase to 1.5 to 2.5 g/kg since CRRT patient’s protein losses are higher.
Secondly, I suggest energy requirement of patient should be estimated at 25 to 40 kcal/kg of
upper end IBW or adjusted IBW per day, and lager intakes of carbohydrate and fat are needed
to prevent the use of protein for energy production. Moreover, his potassium intake should be
about 30-50 mEq/day in oliguric phase that are depending on urinary output, dialysis , and
serum K+ level for replacing losses in diuretic phase; his sodium intake should be about 20-40
mEq/day in oliguric phase which is depending on urinary output, edema, dialysis, and serum
Na1 level for replacing losses in diuretic phase. For Replacing output, we also suggest his fluid
intake increase 500ml more.
14. This patient is receiving the medication propofol. Using the information that you
listed in question #6 and #11, what changes will you make to your nutritional
regimen and how will you assess tolerance to this medication?
The propofol is made by 10% soybean oil emulsion and egg yolk phospholipids, and it is lipid-
based drug that is used to maintain sedation during mechanical ventilation. Propofol can
provide approximately 1.1 kcal/ml infused. Since Propofol is the drug, which is higher in fat,
we need to monitor patient’s level of lipid or fat in his enteral formula. Moreover, we also can
assess tolerance by monitor level of lipid, carbon dioxide, and glucose in patient’s lab results.
15. Identify at least two of the most pertinent nutrition problems and the corresponding
nutrition diagnoses.
Inadequate energy intake related to level 2 trauma with 40% total body surface area burns as
evidence by actual body is 20lb less than the idea body weight and actual body weight is 88%
of ideal body weight.
Inadequate energy intake related to level 2 trauma with 40% total body surface area burns as
evidence by total protein level (4.7g/dL), Albumin level (2.1g/dL), and Prealbumin level(12
mg/dL) are all lower than normal range.
V. Nutrition Intervention
17. 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 patient’s calculated needs using the Xie equation.
1.3 kcal/mL
Base on our calculation, we figure the Impact with Glutamine @ 60 mL/hr is providing
1872kcal and 112g protein for the patient. When we are comparing this amount energy and
protein intake to estimate energy of Xie equation, both energy and protein intake are lower
than the recommend amount. Therefore, we change the Impact with Glutamine to 93 mL/hr
for his enteral formal. By the way, he can meet his recommended energy intake, but this
formula is providing extra 12g protein for him. I decide to give him little bit more protein since
he has acute kidney injury which also since CRRT patient’s protein losses are higher.
https://www.healthproductsforyou.com/p-nestle-impact-glutamine-immunonutrition-for-
surgical-and-trauma-patients.html
18. By using the information on the intake/output record, determine the energy and
protein provided during this time period. Compare the energy and protein provided
by the enteral feeding to your estimation of Mr. Angelo’s needs.
Base on the information on the intake/output record, We find out his enteral feeding is about
565mL. Since he is using Impact with Glutamine @ 60mL/hr, His total energy intake is
(565mL x 1.3kcal/mL= 735kcal), and his total protein intake is [(735kcal x 24%)/4= 44g].
When we are comparing the energy and protein provided by the enteral feeding to your
estimation of Mr. Angelo’s needs, we figure he need 2165kcal more energy intake to meet his
recommend amount(2900kcal-735kcal=2165kcal), and he also need at least 78g more protein
to meet the range for protein requirement(122g-44g=78g).
19. One of the residents on the medical team asks you if he should stop the enteral
feeding because the patient’s blood pressure has been unstable. What
recommendations can you make to the patient’s critical care team regarding enteral
feeding and hemodynamic status?
My recommendation is stopping the enteral feeding because patient can initiate enteral
feeding only when he is hemodynamically stable. When patient is in the setting of
hemodynamic instability which has large volume requirements or use of high-dose
catecholamine agents, the enteral feeding should be stopped until the patient is resuscitated
fully or stable to minimize risk of ischemic or reperfusion injury.
20. List factors that you would monitor to assess the tolerance to and adequacy of
nutrition support.
I would monitor
- the condition of wound healing
- Daily input/output
- Bodyweight
- adequacy of nutrition intake
- Level of total protein, Albumin, and Prealbumin
- Tolerance for pain
- Any unexpected complication
21. What is the best method to assess calorie needs in critically ill patients? What are
the factors that need to be considered before the test is ordered?
The Best method to assess calories needs in critically ill patients is Indirect calorimetry (IC). It
is a commonly used method for measuring energy expenditure, and it is measurement of
oxygen consumed and carbon dioxide expired with a subsequent calculation of energy
requirements from these data. The Indirect calorimetry is the most accurate method of
measuring REE/RMR in clinical setting. Before the test is ordered, the patient should have a
minimum of a 5-hour fast after meal and snacks, and caffeine should be avoided for at least 4
hours, and alcohol and smoking for at least 2 hours. The testing should occur no sooner than
2 hours after moderate exercise or after vigorous resistance exercise. Moreover, for achieving
a steady-state measurement, there should be a rest period of 10 to 20 minutes before the
measurement is taken.
22. Write an ADIME note that provides your nutrition assessment and enteral feeding
recommendations and/or evaluation of the current enteral feeding orders.
Assessment
Mr. Angelo is a 65-year-old male admitted as a level 2 trauma with 40% total body
surface area burns after being involved in a trailer fire. He is admitted to the surgical
intensive care unit for management of burn injury. Patient is unclear about what
occurred, and his story changed several times during assessment. He received 1650 cc of
normal saline en route to hospital. The burn involves the face, bilateral upper extremity,
bilateral lower extremity circumferentially, scrotum, back, and buttocks. The ENT service
evaluated the patient and performed a nasopharynxgolaryngoscopy. Findings included
laryngeal edema and soot on the vocal cords bilaterally.
Anthropometric:
o Hight :72”
o Weight: 71.2kg
o BMI: 21.3
o IBW:178lb
o %IBW: 88.2%
o BSA= 1.9 m2
Lab Result
o High Creatinine Serum level (1.36 mg/dL)
o Low Bicarbonate level (19 mEq/L)
o Low Magnesium level (1.4 mg/dL)
o Low Calcium level (6.9 mg/dL)
o Low Anion gap (5.0 mmol/L)
o Low protein (4.7 g/dL)
o Low Albumin (2.1 g/dL)
o Prealbumin (12 mg/dL)
o High AST level (44 U/L)
o High WBC
o High Hemoglobin
o High Hematocrit
Clinical
o NPO with TF Impact with Glutamine @ 60 mL/hr
o LR @ 610 mL/hr × first 8 hours and decrease to 305 mL/hr × 16 hours
o Ascorbic acid 500 mg every 12 hours
o Chlorhexidine 0.12% oral solution 15 mL every 12 hours
o Famotidine tablet 20 mg every 12 hours
o Heparin injection 5,000 units every 8 hours
o Insulin regular injection every 6 hours
o Multivitamin tablet 1 tab daily
o Zinc sulfate 220 mg daily
o Methadone 5 mg every 8 hours
o Oxandrolone 10 mg every 12 hours
o Senna tablet 8.6 mg daily
o Docusate oral liquid 100 mg every 12 hours
o Silver sulfadiazine 1% cream topical application daily
o Midazolam HCl (Versed) 100 mg in sodium chloride 0.9% 100 mL IV infusion,
initiate infusion at 1 mg/hr
o Hydromorphone (Dilaudid) injection 0.5–1 mg, intravenous every 3 hours as
needed
o Fentanyl (Sublimaze) injection 50–100 mcg intravenous every 15 minutes as
needed
o Propofol (Diprivan) 10 mg/mL premix infusion, start at 25 mcg/kg/min
intravenous continuous
o Thiamin 100 mg 3 3 days
o Folate 1 mg 3 3 days
Diagnosis
Inadequate energy intake related to level 2 trauma with 40% total body surface area
burns as evidence by actual body is 20lb less than the idea body weight and actual
body weight is 88% of ideal body weight.
Inadequate energy intake related to level 2 trauma with 40% total body surface area
burns as evidence by total protein level (4.7g/dL), Albumin level (2.1g/dL), and
Prealbumin level(12 mg/dL) are all lower than normal range.
Intervention:
Base on our calculation, we figure the Impact with Glutamine @ 60 mL/hr is providing
1872kcal and 112g protein for the patient. When we are comparing this amount
energy and protein intake to estimate energy of Xie equation, both energy and protein
intake are lower than the recommend amount. Therefore, we change the Impact with
Glutamine to 93 mL/hr for his enteral formal. By the way, he can meet his
recommended energy intake, but this formula is providing extra 12g protein for him. I
decide to give him little bit more protein since he has acute kidney injury which also
since CRRT patient’s protein losses are higher.