I. Understanding the Diagnosis Pathophysiology
1. Describe how burn wounds are classified. Identify and describe Mr. Angelo’s burn injuries.
Burn wounds are characterized into four classifications. The first classification is
superficial. The cause of this is through ultraviolet light or a very short flash. The appearance
of this wound is dry and red and blanches with pressure. It is painful but heals in 3 to 6 days,
leaving no scar. The second classification is a superficial partial-thickness wound. This is
caused by a scald (spill or splash), and/or short flash. The appearance involves blisters as well
as moist, red, and weeping. It blanches with pressure and is painful to air and temperature and
will heal in 7 to 20 days. The scarring of this classification is unusual, but pigmentary changes
are possible. The third classification is deep partial-thickness. The cause is by a scald (spill),
flame, oil, and/or grease. It has a blistered appearance, is wet or waxy dry, has a variable color
of patchy to cheesy white to red, and does not blanch with pressure. It is perceptive of pressure
only, and will take more than 21 days to heal. The scarring is severe and hypertrophic and has
a risk of contracture. The last classification is a full thickness burn. It is caused by a scald
(immersion), flame, steam, oil, grease, chemical, and or high-voltage electricity. The
appearance has a waxy white to leathery gray to charred and black color, is dry and inelastic,
and does not blanch with pressure. It has sensation to deep pressure only. This classification
of burn will never heal if the burn affects more than 2% of the total surface area of the body.
The scarring has a very severe risk of contracture.
(pg. 693)
Mr. Angelo’s burns can overall be classified as a full thickness burn due to the fact that
40% of his total body surface area is burned. The cause of his burns are from a trailer fire. The
wounds generally appear to have ruptured blisters and devitalized skin. The patient does not
have any range of motion to the affected area. The burns involve his entire face, singed
eyebrows, hair, and facial hair. There is soot noted in nares and oropharynx. 1st degree burns
were reported near the umbilicus as well as 2nd degree burns noted on right bicep, forearm,
hand, left bicep and hand, and on mid to left back. Blistering noted at head of penis and
scrotum. Full thickness burns were noted to bilateral lower extremities.
Nahikian-Nelms, M., & Roth, S. L. (2013). Medical nutrition therapy: A case study
approach. Stamford, Connecticut: Cengage Learning.
2. Explain the “Rule of Nines” used in assessment of burn injury.
The “Rule of Nines” is one method that is used to make a rapid estimation of body
surface area that has been burned. This method includes dividing the body into portions with a
value or derivative of nine. For example, the entire head is estimated to be approximately 9% of
the total body area. This method is not only used to estimate the affected body surface area but
also assists in the assessment of the extent of the injury, and helps provide the basis for
prescribing fluid and medication. Figure 22.6 from the reading is provided below to show all
estimations of body surface area.
(pg. 693-694)
3. Mr. Angelo’s 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 patients for fluid
resuscitation? What are the components of this solution?
The primary goal of fluid resuscitation is to anticipate prevent hypovolemic shock.
Hypovolemic shock is an emergency condition in which severe blood and fluid loss cause the
heart to stop pumping enough blood to the body; it can cause many organs to stop working.
Symptoms of hypovolemic shock include anxiety, cold and clammy skin, confusion, decreased
or no urine output, general weakness, pale skin color, rapid breathing, sweating, and
unconsciousness. Hypovolemic shock can develop if fluid is not replaced in patients with burns
involving greater than 15-20% total body surface area (TBSA). The Parkland formula is a guide
which assists in the estimation of fluid requirements. It is a formula used to calculate the
amount of resuscitation fluid required for the first 24 hours in a burn victim to ensure they remain
hemodynamically stable. The fluid required for the first 24 hours is four times the product of the
body weight and the body surface area affected by burns (3 – 4 mls/kg/TBSA% = mls/ given in
24 hours post injury). The calculation of this fluid requirement is calculated from the time of the
burn instead of the time of presentation. If the presentation is delayed, fluid may need to be
given more rapidly. Ongoing fluid volume replacement must be determined by clinical
indicators. Hartmanns is the preferred intravenous fluid for resuscitation in burn patients. The
components of this fluid include sodium, sodium chloride, sodium lactate, potassium chloride,
and calcium. One liter of Hartmanns solution contains 131 mEq sodium, 111 mEq sodium
chloride, 29 mEq sodium lactate, 5 mEq potassium chloride, 4 mEq calcium.
Hypovolemic shock: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/000167.htm
Victorian Burns Unit. (n.d.). Retrieved from http://www.vicburns.org.au/initialmanagement/primary-survey/circulation-commence-fluid-resuscitation.html
4. What is inhalation injury? How can it affect patient management?
An inhalation injury is one of the most devastating types of trauma resulting from
exposure to fire and smoke. Even though many people associate only smoke with these types
of injuries, it is not the only thing that can cause an inhalation burn. Inhaling gases and other
toxic fumes can cause damage as well. These injuring are challenging because symptoms can
be subtle or non-existent for the first 24-36 hours after the initial burn. Diagnosing these signs
right away is critical for recovery and to minimize long-term damage. These injuries can range
from irritation of the nose and throat to significant damage to the airway and lungs. When
assessing if a patient has suffered an inhalation injury, the following signs and symptoms should
be noted: burns to the nose, lips, brows, or neck, soot in the sputnum, singed nose hairs,
shortness of breath, hoarseness in voice, throat pain, wheezing or coughing, nausea,
sleepiness, confusion, and/or burns to a large area of the body. Tests to diagnos an inhalation
injury include a chest x-ray, chest CT scan, CT scan of the brain, ECG to test the electrical
activity of the heart, and pulmonary function tests. These diagnosis tests help the medical
professionals understand the severity of the injury. Treatment varies widely based on the
severity of the injury. It can affect patient management because some of the treatments may
interfere with other interventions such as surgeries or nutritional intervention. For example, the
patient may not be able to swallow properly due to the amount of air; therefore the nutrition
intervention would be affected. Some treatments include humidified oxygen to help restore
oxygen levels in the airway and lung tissues, bronchodilators to help relax and dilate the
bronchial passageways to improve the passage of air into the lungs, suction to remove
excessive fluid from the airways, an endotracheal tube to deliver oxygen or perform suction of
mucus, and or antibiotics to control infection.
Shriners Hospitals for Children - Inhalation Injuries. (n.d.). Retrieved from
http://www.shrinershospitalsforchildren.org/CareAndTreatment/Burns/InhalationInjuries.
aspx
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.
Patients with burn injuries are at significant nutritional risk due to the hypermetabolic,
catabolic response that occurs after the injury. As much as 20% of body protein can be lost
within the first two weeks of burn injury; therefore protein requirements can be increased to 1.52 g protein/kg. Patients with extensive burns have trouble maintaining his or her nutritional
status due to fluid imbalance, pain, and immobility. Weight may change rapidly due to fluid
shifts and resuscitation. Other factors such as fever, infection, or the development of sepsis
contribute to increased energy. Nutrition requirements also increase for vitamins, minerals, and
trace elements such as vitamin C, vitamin A, vitamin E, zinc, copper, and selenium for wound
healing and to ensure adequate support for engraftment and overall wound healing.
pg. 695
6. List all medications that Mr. Angelo is receiving. Identify the action of each medication and
any drug-nutrient interactions that you should monitor.
Medication
Drug-nutrient Interaction
Ascorbic acid
None
Chlorhexidine
None
Famotidine
Minor interaction with nicotine
Heparin injection
Minor interaction with antihistamines,
antithrombin III, digoxin, mifepristone, nicotine
(e.g., patch, gum), nitroglycerin given by
injection, other drugs that can cause
bleeding/bruising
Insulin
Avoid alcohol if diabetic
Multivitamin
None
Zinc sulfate
Take 1-2 hours after or before meal (food
may decrease absorption of zinc sulfate)
Methadone
Grapefruit juice can increase blood levels,
should be avoided when on methadone.
Avoid alcohol and medications that contain
alcohol
Oxandrolone
None
Senna
None
Docusate oral liquid
None
Silver sulfadiazine
None
Acetaminophen
Alcohol should be avoided
Midazolam
Alcohol and grapefruit/grapefruit juice should
be avoided
Hydromorphone injection
DO NOT consume alcohol or any food
containing alcohol
Fentanyl injection
DO NOT consume alcohol or any food
containing alcohol
Propofol
Avoid alcohol; watch calorie intake
Thiamin
None
Folate
None
Feel Better - Find Nutrients Depleted by Medication - Nutrient Depletion Calculator Mytavin.com. (n.d.). Retrieved from http://mytavin.com/
II. Understanding the Nutritional Therapy
7. Using evidence-based guidelines, describe the potential benefits of early enteral nutrition in
burn patients.
Enteral nutrition that has been initiated within 24 hours of injury has been associated
with the prevention of infections (bacterial translocation specifically) and preventing Curling’s
ulcer, and the reduction of protein catabolism (pg. 695). Immediate enteral feeding is safe and
effective for burn patients to deliver nutritional support but initial complications/concerns are
vomiting. Early EN is used to maintain gut integrity, modulate stress and the systemic immune
response, and attenuate disease severity. (ASPEN guidelines)
Immediate enteral feeding in burn patients is safe and effective. (n.d.). Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1358391/
8. What are the common criteria used to assess readiness for the initiation of enteral nutrition in
burn patients?
To assess readiness for the initiation of enteral nutrition in burn patients, evaluation of
weight loss and previous nutrient intake prior to admission should be looked at. Also the level of
disease severity, comorbid conditions, and functions of the GI tract should be assessed.
Enteral nutrition should be initiated in a critically ill patient who is unable to maintain volitional
intake. Energy requirements may be calculated by equations or measured using indirect
calorimetry. Predictive equations usually provide a less accurate measure of energy
requirements than indirect calorimetry. A patient with a BMI <30 require protein levels of 1.5-2.0
g/kg per day and may be higher in burn or multi-trauma patients. Enteral nutrition should be
initiated and monitored daily for tolerance, and gradually work up to the final nutrient goal.
A.S.P.E.N. Guidelines and Standards Library. (n.d.). Retrieved from
http://www.nutritioncare.org/library.aspx
9. What are the specialized nutrient recommendations for the enteral nutrition formula
administered to burn and trauma patients per ASPEN/SCCM guidelines?
There are many predictive formulas designed to estimate energy needs of burn patients.
The older formulas tend to overestimate requirements because they were developed before
improvements in burn care which have reduced the hypermetabolic response. Other formulas
do not account for environmental conditions such as temperature, skin grafting, dressing
changes, and variations in activity. The limitations increase the need for regular monitoring and
follow up of patients to avoid overfeeding and ensure adequate nutrition. When calculating
requirements it is important to use the ideal/usual body weight (except with use of Ireton-Jones
equation), reassess at least twice weekly as wounds begin to close and heal, consider graft
mesh size, consider the impact and continuum of physiotherapy and
occupational therapy using the activity factors. The Toronto Formula is useful in the acute
stages of burns, the Modified Harris Benedict and Modified Schofield are also
been used with patients with burn injury. The Ireton-Jones Equation is used in the Intensive
Care setting. The formulas are written below.
Toronto Formula:
For all patients:
REE (kcal) = -4343 + (10.5 x TBSA burned) + (0.23 x kcals) +
(0.84 x Harris Benedict) + (114 x T (oC)) - (4.5 x days post-burn)
Modified Harris Benedict Equation:
Male:
BEE (kJ) = 278 + (57.5 x kg Wt) + (20.9 x cm Ht) – (28.3 x age)
Female:
BEE (kJ) = 2741 + (40 x kg Wt) + (7.7 x cm Ht) – (19.6 x age)
Modified Schofield Equation:
Female kcal/d BMR:
15-18 years 13.3W + 690
18-30 years 14.8W + 485
30-60 years 8.1W + 842
Over 60 years 9.0W + 656
Male kcal/d BMR:
15-18 years 17.6W + 656
18-30 years 15.0W + 690
30-60 years 11.4W + 870
Over 60 years 11.7W + 585
Agency for Critical Innovation (2011). Clinical practice guidelines nutrition burn patient
management. ACI NSW Agency for Clinical Innovation, 3, 13-14.
10. What additional micronutrients will need supplementation in burn therapy? What dosages
are recommended?
-Glutamine and omega-3 fatty acids for promotion of wound healing
-Vitamin C, Vitamin A, vitamin E, and Zinc are used to help with enfragment and wound
healing
- Glutamine = oral dose of 0.57 mg/kg/d in adults (pg. 168)
-Arginine = oral doses of 17.0-18.0 g/day
- Zinc- 15-25 mg elemental
-vitamin C- 1-2 mg/day
- vitamin E, thiamin, riboflavin, pantothenic acid- 100% of DI
McClave, S., Martindale, R., & Vanek, V., et al., (2009). Guidelines for the provision and
assessment of nutrition support therapy in the adult critically ill patient: Society of critical care
medicine (sccm) and american society for parenteral and enteral nutrition (a.s.p.e.n.). Journal of
Parenteral and Enteral Nutrition, 33(3), 277-316. doi: 10.1177/0148607109335234
Prelack, K., Dylewski, M., & Sheridan, R. (2006). Practical guidelines for nutritional management
of burn injury and recovery. ELSEVIER, (33), 14-24. doi: 10.1016/j.burns.2006.06.014
III. Nutrition Assessment
11. Using Mr. Angelo’s height and admit weight, calculate IBW, % IBW, BMI, and BSA.
The Hamwi equation is used to calculate ideal body weight for men and women. In
clinical settings, this equation is used even though it does not take into account differences in
age, race, or frame size.
IBW Men: 106 lbs. for 5 ft. + 6 lbs. per in. over 5 ft.
IBW = 106 + [6 (12 in.)] = 178 lbs.
IBW =178 lbs. / 2.2 = 80.9 kg
%IBW = (current weight/ ideal body weight) x 100
%IBW = (71.2 kg/80.9 kg) x 100
%IBW = 88.0%
BMI = kg/m2
BMI = (71.2 kg / (1.83 M2)
BMI = 21.26 kg/M2
BSA = (kg 0.425 x cm 0.725) x 0.007184
BSA= (80.9kg 0.425 x 182.88cm 0.725 = (108.906 kg x 377.598 cm) = 41,143.078 x 0.007184=
295.57
BSA = 2.029 M2
(pg. 48)
Body Surface Area. (n.d.). Retrieved from http://wwwusers.med.cornell.edu/~spon/picu/calc/bsacalc.htm
12. 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?
Zawacki Equation:
RMR = 1440/BSA (m2)
RMR = 1440/ 2.029 m2
RMR = 2921 kcal/day
Xie Equation:
RMR = (1000/BSA [m2] + (25 x BSAB)
RMR = (1000/2.029 m2 + (25 x 40%)
RMR = 3029 kcal/day
[A nutrition formula for adults with ... [Zhonghua Wai Ke Za Zhi. 1992] - PubMed - NCBI.
(n.d.). Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/1288998
13. Determine Mr. Angelo’s protein requirements. Provide the rationale for your estimate.
= 1.5-2 g protein/ Kg
= 80.9 Kg x 1.5 g = 121.35 g
= 80.9 kg x 2 g = 161.8 g
= 121 - 161 grams of protein/ day
This amount is recommended to help minimize losses and promote wound healing.
Monitoring daily provides practical measurements of adequate nutritional support. Even though
a range was calculated, it is recommended that Mr. Angelo gets closer to 161 grams of protein
per day rather than 121 grams of protein per day due to his high total body surface area
affected by the wounds.
(pg. 695)
14. The MD’s progress note indicates that the patient is experimenting 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?
- “Clinically Acute Kidney Injury (AKI) is characterised by a rapid reduction in kidney
function resulting in a failure to maintain fluid, electrolyte and acid-base homoeostasis.”
Lewington, A., & Kanagasundaram, S. (2011, March 08).Acute kidney injury. Retrieved from
http://www.renal.org/clinical/guidelinessection/AcuteKidneyInjury.aspx
- If the patient’s renal function continues to deteriorate we would monitor his weight and
sodium. If his sodium was extremely high and he was not coming up in weight we would need to
change from a 1 cc fluid/ kcal formula to possibly a 1.5 kcal/cc or a NEPRO formula in order to
get the same amount of Kcal with less protein for the kidneys to be able to handle the formula.
If we need to pull back on fluid, we would look at formula like Magnical with 2 kcal/cc (less fluid)
or Nepro.
15. This patient is receiving the medication propofol. Using the information that you listed in
question #6, what changes will you make to your nutritional regimen and how will you assess
tolerance to this medication?
● Because Propofol is a drug that is higher in fat, it is important to monitor the
enteral formula for level of lipid in order to ensure the patient is not getting too
much lipid intake in combination with medicine. The ccs in the formula for the
patient’s enteral nutrition will need to be decreased by however many ccs of
propofol the patient is given in order to prevent increased glucose levels CO2.
● The patient’s tolerance to this medication can be monitored by his lab values of
glucose, lipid, and CO2.
Greenwood, J. (2009, July 12). Icu guideline: Adjusting goal feed rates in the patient receiving a
propofol infusion. Retrieved from http://www.criticalcarenutrition.com/docs/tools/Propofol.pdf
Lowrey, T., Dunlap, A., Brown, R., Dickerson, R., & Kudsk, K. (1996). Pharmacologic influence on
nutrition support therapy: Use of propofol in a patient receiving combine enteral and parenteral
nutrition support. Nutriton Clinical Practices,11(4), 147-149. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/9070015
IV. Nutrition Diagnosis
16. Identify at least 2 of the most pertinent nutrition problems and the corresponding nutrient
diagnoses.
1. Inadequate energy intake (NI-1.2)
2. Inadequate protein intake (NI-5.7.1)
Academy of Nutrition and Dietetics (2013). International dietetics and nutrition
terminology (IDNT) reference manual: Standardized language for the nutrition care
process. Chicago, IL: Academy of Nutrition and Dietetics.
17. Write your PES statements for each nutrition problem.
1. Inadequate energy intake (NI-1.2) related to level 1 trauma with 40% total body surface area
burns as evidence by BMI of 21 kg/m2 and difference of 10 kg between actual body weight and
ideal body weight.
2. Inadequate protein intake (NI-5.7.1) related to level 1 trauma with 40% total body surface
area burns as evidence by low total protein level of 4.7 g/dL, low albumin level of 2.1 g/dL, and
low prealbumin level of 12 g/dL.
V. Nutrition Intervention
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
patient’s calculated needs using the Xie equation.
Impact with Glutamine @ 60 mL/hr
Energy provided:
1.3 kcal/mL
60 mL x 1.3 kcal/mL = 78 kcal
78 kcal/hr x 24 hours = 1872 kcal/day
Protein provided:
24% protein
1872 kcal x 24% = 449.28 kcal from protein
449.28 kcal/ 4 kcal/g = 112 g protein
Energy needed:
Based on the Xie equation, our patient needs 3029 Kcal/day
3029 Kcal/1.3 mL / 24 hours = 97 mL/hr
Protein needed:
Based on calculations, our patient needs 121-161 g protein/day
3029 kcal x 24% = 726 kcal from protein
726 kcal / 4 kcal/g = 181 g protein
Guidelines to meet the patient’s calculated needs contain the following recommendations. Right
now, Mr. Angelo is receiving 60 mL/hr, yet to get him the amount of calories he needs, he would
need to receive 97 mL/hr. This is almost doubling the volume he is currently receiving. Mr.
Angelo is likely to not tolerate this amount; therefore his residuals, lab values, input/output, and
other signs such as diarrhea and vomiting should be monitored to see if Mr. Angelo is tolerating
this enteral feeding. If Mr. Angelo is tolerating 60 mL/hr, it would then be appropriate to
increase the volume to 70 mL/hr the next day, 80 mL/hr the day after, and so on. By advancing
Mr. Angelo to 97 mL/hr, he would then be getting 3029 kcal and 181 g protein which is higher
than the recommended amount, but it is unlikely Mr. Angelo will be able to tolerate this amount
of formula. In this case, it may be appropriate to look into a formula that has a higher kcal/mL
ratio such as Nepro with Carb Steady which would give him 1.8 kcal/mL. This would then give
him more calories with less volume which may be more tolerated by Mr. Angelo.
Homepage | Clinical Nutrition | Nestlé Nutrition - Nestle-Nutrition.com. (n.d.). Retrieved
from http://www.nestle-nutrition.com/Public/Default.aspx
19. 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 estimate of Mr. Angelo’s needs.
Mr. Angelo is taking in 565 mL of Impact in 24 hours. Since this formula has a 1.3
kcal/mL ratio, this means that Mr. Angelo is receiving 734 kcal over the course of 24 hours.
Impact formula contains 22% protein, therefore Mr. Angelo is receiving 44 g protein over the
course of 24 hours. This means that Mr. Angelo is receiving 2295 less calories than needed as
well as approximately 117 less grams of protein than needed. Since this is Mr. Angelo’s first
intake/output record, this is accurate and understanding. Even though the goal is to get Mr.
Angelo up to these calories and protein, his focus should be on getting enough fluid and
micronutrients in his body right now. One he is able to tolerate these IV solutions, then an
increase in his enteral feedings will slowly be increased. The hospital does not want to keep
him on this low calorie and low protein intake more than 2-3 days because it can cause other
health problems such as malnutrition. As soon as tolerated, Mr. Angelo should be advanced to
a higher volume of Impact per hour. As stated in question 18, his nutritional intake needs to be
monitored daily to assess if he is tolerating new amounts of the feedings or if a new formula
needs to be tried.
Nepro® with Carb Steady®. (n.d.). Retrieved from
http://abbottnutrition.com/brands/products/nepro-with-carb-steady
20. One of the residents on the medical team asks you if he should stop the enteral feedings
because the patient’s blood pressure has been unstable. What recommendations can you
make to the patient’s critical care team regarding tube feeding and hemodynamic status?
If his Intake and Output numbers look good, his pre-albumin is improving, residuals are
fine, then that is a sign he is healing. If he is gaining weight on the formula then there is no
reason to stop the enteral nutrition. His blood pressure could try to be resolved in a different way
because his Enteral Nutrition does not appear to be causing the high blood pressure and the
enteral nutrition shows to be helping him heal. (Professor Matuszak). His blood pressure was
also elevated upon arrival to the hospital so the enteral nutrition most likely did not cause this
elevated blood pressure.
VI. Nutrition Monitoring and Evaluation
21. List factors that you would monitor to assess the tolerance to and adequacy of nutrition
support.
● Input and output numbers
● Pre- albumin
● Residuals are normal
● Wounds are healing
● Gaining weight
● Pain tolerance
● No complications such as vomiting and diarrhea
22. 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?
Indirect calorimetry is the best method to assess calorie needs. Since energy
requirements can vary from patient to patient, indirect calorimetry is the best method for
determining energy requirements because it takes away estimation and generalizations made
by formulas and other manners. It can also help prevent over or under feeding. Before ordering
an indirect calorimetry test, the patient’s burns and wounds must be considered. He does not
have severe facial or neck burns so it would be reasonable to do the test. However, the patient
does have a lot of deep and open wounds among his body so he will be losing a lot of extra
fluids and expending calories through that manner that would not be accounted for in the
indirect calorimetry. The nutrient recommendations would need to be higher than that shown of
just his regular resting breathing rate in the indirect calorimetry.
Prelack, K., Dylewski, M., & Sheridan, R. (2006). Practical guidelines for nutritional management
of burn injury and recovery. ELSEVIER, (33), 14-24. doi: 10.1016/j.burns.2006.06.014
23. Write an ADIME note that provides your nutrition assessment and enteral feeding
recommendations and/or evaluation of the current enteral feeding orders.
●
A
○
○
○
A: 65 year old male that is 72” and 156 lbs. Ideal body weight of 178 lbs, body
mass index of 21 kg/m2, and body surface area of 2.029 m2.
B: Lab values indicate increased potassium, chloride, creatinine serum, glucose,
ALT, AST, WBC, hemoglobin, and hematocrit levels. Lab values indicate low
magnesium, calcium, total protein, albumin, prealbumin, pH, and HCO3-.
C: Patient admitted as a level 2 trauma with 40% total body surface area burns
after being involved in a trailer fire. The burns involve his entire face, singed
eyebrows, hair, and facial hair. There is soot noted in nares and oropharynx. 1st
degree burns were reported near the umbilicus as well as 2nd degree burns
noted on right bicep, forearm, hand, left bicep and hand, and on mid to left back.
Blistering noted at head of penis and scrotum. Full thickness burns were noted
to bilateral lower extremities.
○
D: NPO with EN. Impact with GLutamine @ 20 mL/hr, advance 20 mL/hr every 4
hours to 60 mL/hr. Final goal rate per RD.
● D
1. Inadequate energy intake (NI-1.2) related to level 1 trauma with 40% total body surface area
burns as evidence by BMI of 21 kg/m2 and difference of 10 kg between actual body weight and
ideal body weight.
2. Inadequate protein intake (NI-5.7.1) related to level 1 trauma with 40% total body surface
area burns as evidence by low total protein level of 4.7 g/dL, low albumin level of 2.1 g/dL, and
low prealbumin level of 12 g/dL.
● I
Increase rate of enteral nutrition as patient tolerates. Final goal is to increase rate to 126 mL/hr
to increase calories to 3029 kcal and protein to 181g. If patient is not tolerating volume amount,
Nepro with Carb Steady formula may want to be considered, which will provide 1.8 kcal/mL.
● M/E
Monitor lab values weekly to assess protein levels and micronutrient levels are increasing.
Monitor input/output values, residuals, and weight gain to assess if patient is tolerating enteral
feeding. Also monitor wound healing. Reevaluate indirect calorimetry weekly to assess
patients calorie and protein needs during healing.