Burnvictimcasestudy

Running Head: CASE STUDY OF A BURN VICTIM
Case Study of a Burn Victim

Tallene Hacatoryan, Cory Ruth, Sarah Pruett Soufl,
Alyssa Snow Callahan, and Meghry Achekian
NTRS 415B
May 15, 2015
CASE STUDY OF A BURN VICTIM

Subjective / Objective Data
PI: JA is a 65 YOWM admitted to the surgical ICU on September 9th as a level 2 trauma with
40% total body surface area (TBSA) burns after being involved in a trailer fire.
CC: The patient was unclear about what has occurred and changed his story a few times during
assessment. He has been intubated so he did not offer a chief complaint upon admission to the
hospital.
HPI: The patient was driving behind an RV that caught on fire. He was in the front cab of the
RV trying to put out an engine fire when his clothes caught on fire. He jumped out and started
rolling on the ground to put out the flames. At one point, he claimed that he jumped into a ravine,
but later this was not the case. His burns involve the face, bilateral upper and lower extremities
(both sides of both arms and legs), scrotum, back, and buttocks. The EMTs evaluated the patient
and performed a nasopharyngolaryngoscopy and found laryngeal edema and soot on the vocal
cords bilaterally (on both sides).
PMH:
The patient has been previously diagnosed with diabetes, hypertension (HTN; high blood
pressure), and gastroesophageal reflux disease (GERD; disease in which stomach acid
flows backward into the esophagus).
His surgical history includes a cholecystectomy 30 years ago for treatment of gallstone
complications.
The patient takes no medications at home.
FH: Both of the patients parents have hypertension. His mother also has an anxiety disorder.
The patients brother is in normal health.


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SH: The patient has smoked one pack/day for 30 years. He drinks 2-3 beers daily and increases
to a case/day on weekends. He is single and his religion is unknown. He recently became
unemployed in Atlanta, and was moving in with his parents and brother. The geographic area his
family resides in and his family responsibilities are unknown.
PE: His burns involve the face, bilateral upper and lower extremities, scrotum, back, and
buttocks. He is experiencing laryngeal edema and has soot on his vocal cords bilaterally. The
patient has occasional wheezing, along with patchy infiltrates found on his chest X-ray (most
likely related to smoking). His airway is intact, and his breathing is clear. The patient is alert,
cooperative, in mild distress, and appears his stated age. The wounds appear to have ruptured
blisters and devitalized skin. The patients range of motion (ROM) near the affected area has
diminished due to severe pain.
Temp: 100F
Pulse: 120 bpm
Respiration rate: 22 breaths per minute
SpO2: 98%
BP: 140/93 mm Hg
Height: 72 in.
Weight: 71.2 kg (157 lbs.)
General Appearance: intubated, sedated
Head: Burns involving entire face, signed eyebrows, hair, and facial hair
Head/Face: Non-rebreather mask in place
Eyes: PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation)


Ears: Clear
Nose: Soot noted in nares and oropharynx
Throat: Dry mucous membranes
Neck: C-collar in place
Lungs: Clear to auscultation bilaterally
Heart: Tachycardia, regular rhythm; S1, S2 normal, no murmur, click, rub, or gallop
Abdomen: Soft, non-tender. Bowel sounds normal. No masses, no organomegaly, partial

thickness and 1st degree burns near umbilicus
Upper Extremities: Burns noted R bicep, forearm, hand, left bicep and hand, mostly
second degree. Skin sloughing and devitalized tissue
Lower Extremities: Mostly full thickness burns noted to bilateral lower extremities
circumferentially
Back: Second degree burns in mid and left back
Partial thickness burns over lower back and buttocks
Genitourinary Erythema and blistering at head of penis and scrotum
Right Pulses: FEM: present 2+, POP: present 2+, DP: present 1+, PT: present 1+
Left Pulses: FEM: present 2+, POP: present 2+, DP: present 1+, PT: present 1+
Assessment
65 year-old male presented as level 2 trauma with 40% total body surface area burns. He
was intubated on arrival to the surgical intensive care unit for airway protection. The burn
team plans to conduct a bronchoscopy. The patient shows signs of significant respiratory
acidosis. The trauma team performed an escharotomy (surgical treatment to burned tissue


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in which the remaining dermis and epidermis are destroyed) on bilateral (both sides) of
his lower extremities overnight. His blood pressed decreased overnight and he became
hypotensive. He received 4 L of fluids.
The burn team plans to continue to manager his 40% TBSA burn by Continuing daily
dressing changes. Surgeries are scheduled for debridement and split thickness skin
grafting.
He was intubated for airway protection and a bronchoscopy is scheduled.
He is sedated and his pain is managed with versed gtt, Dilaudid, fentanyl prn, and
methadone will be increased to 10 mg every 8 hours. He will be weaned off Propofol by
the end of the day and his current rate is 25 mL/hr.
The patient is experiencing hyperkalemia, which is secondary to metabolic, respiratory
acidosis. His hyperkalemia is improving as his last serum potassium level is 5.9 mEq/L.
The burn team plans to continue to resuscitate with Lactated Ringers solution.
The patient is in a state of protein-calorie malnutrition. The physician recommends
advancing tube feeding to goal rate per RD.
He has an acute kidney injury, which will be addressed by continuing fluid resuscitation.


Hospital Treatment Course
Date: 9/9 (7:00 a.m.) - 9/10 (6:59 a.m.)
Diagnoses:
Level 2 Trauma with 40% TBSA burns
Laryngeal edema and soot on vocal cords bilaterally
Respiratory failure
Hyperkalemia (improving)
Hypotensive
Respiratory acidosis
Acute pain due to injury
Oliguria
Protein-calorie malnutrition
Medications:
Ascorbic Acid (500 mg every 12 hrs.)
Chlorhexidine (0.12% oral solution, 15 mL every 12 hrs.)
Famotidine tablet (20 mg every 12 hrs.)
Heparin injection (5,000 units every 8 hrs.)
Insulin (regular injection, every 6 hrs.)
Multivitamin (1 tablet daily)
Zinc sulfate (22 mg daily)
Methadone (5 mg every 8 hrs.)
Oxandrolone (10 mg every 12 hrs.)


Senna tablet (8.6 mg daily)
Docusate oral liquid (100 mg every 12 hrs.)

Silver sulfadiazine (1% cream topical application only)
Acetaminophen (650 mg oral every 4 hrs., as needed)
Midazolam HCI (Versed) (100 mg in sodium chloride 0.9%, 100 mL IV infusion, initiate
infusion at 1 mg/hr), Dressing change: 2-5 mg intravenous pre- and intra-procedure pain
management
Hydromorphone (Dilaudid) injection (0.5-1 mg, intravenously every 3 hrs., as needed),
0.5-1.5 mg IV prior to dressing change and every 15 min. during if pain score >4/10
Fentanyl (Sublimaze) injection (50-100 mcg intravenously every 15 min. as needed)
Propofol (Diprivan) (10 mg/mL premix solution, start at 25 mcg/kg/min intravenous
continuous)
Thiamin (100 mg x 3 days)
Folate (1 mg x 3 days)
Ketamine (50 mg injection, administer as slow IV immediately prior to dressing change)
Oxycodone (Roxicodone) (5-10 mg, per NG tube every 4 hrs., as needed)
Laboratory Test Results:
Fluid (last three completed shifts):
Intake: 16,425 mL (230.7 mL/kg)
Output: 1,696 mL (23.8 mL/kg)
Urine Output: 1,295 mL (18 mL/kg)
Chemistry:


Sodium: 137 mEq/L (Within normal limits)
Potassium: 5.9 mEq/L (High)
Chloride: 113 mEq/L (High)
Carbon dioxide: 20 mEq/L (Low)
BUN: 13 mg/dL (Within normal limits)
Creatinine serum: 1.26 mg/dL (High)
BUN/Creatinine ratio: 10.3 (Within normal limits, on the lower side)
Glucose: 211 mg/dL (Very high)
Phosphate, inorganic: 3.4 mg/dL (Within normal limits)
Magnesium: 1.5 mg/dL (Low)
Calcium: 6.9 mg/dL (Low)
Osmolality: 295 mmol/kg/H2O (Within normal limits)
Bilirubin total: 1.2 mg/dL (Within normal limits)
Bilirubin direct: 0.2 mg/dL (Within normal limits)
Protein, total: 4.7 g/dL (Low)
Albumin: 2.1 g/dL (Low)
Prealbumin: 12 mg/dL (Low)
Alkaline phosphatase: 70 U/L (Within normal limits)
ALT: 21 U/L (Within normal limits)
AST: 44 U/L (High)
C-reactive protein: 12 mg/dL (Very high)
Coagulation:


PT: 13.7 sec (Within normal limits)
PTT: 26 sec (Within normal limits)

Hematology:
WBC: 18.1 x103/mm3 (High)
RBC: 5.97 x 106/mm3 (Within normal limits)
Hemoglobin: 18.7 Hgb, g/dL (Within normal limits)
Hematocrit: 54.4% Hct (Within normal limits)
Arterial Blood Gases (ABGs):
pH: 7.31 (Low)
pCO2: 39.8 mm Hg (Within normal limits)
SO2: 99.8% (Within normal limits)
pO2: 106.5 mm Hg (Within normal limits)
HCO3-: 19.6 mEq/L (Low)
Current Diet Order: NPO with EN. Impact with Glutamine at 20 mL/hr, and advance 20 mL/hr
every four hours to 60 mL/hr.
Medical Treatment Plan:
In the first 24 hours of hospitalization:
The patients burn was immediately addressed by the burn team. He received an
escharotomy (surgical treatment to burned tissue in which the remaining dermis and
epidermis are destroyed) on both sides of his lower extremities He was positioned so that
any burned extremity was elevated and his head was elevated at a 30 degree angle above
his body to promote blood flow. Moving forward, they will continue daily dressings or


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schedule a debridement (removal of dead skin). Additionally, they may perform a split
thickness skin grafting for transplantation.
Due to respiratory distress, the patient was intubated (a breathing was inserted) today and
he will undergo a bronchoscopy (imaging test of airways) at 11:30 a.m. in Day 2 to
determine how to address respiratory failure.
The patient was received fluid resuscitation via Lactated Ringers solution to address his
trauma, acute kidney injury, and electrolyte imbalances.
The patient was administered pain medication and sedatives. In the following 24 hours,
the patients methadone will be increased to 10 mg every eight hours, and the care team
will utilize versed gtt, dilaudid and fentanyl prn if the patient demonstrates severe
agitation and needs to be more heavily sedated. He was also administered Propofol as a
sedative, and the physician aims to wean him off the Propofol in the next 24 hours.
Brief Nutrition Assessment:
JA is NPO (nothing by mouth) with EN (enteral nutrition). Based on the diet order, he
should be currently receiving 60 mL/hr of Impact with Glutamine and 25 mL/hr of Propofol,
which would add up to a maximum of 2,220 kcal/day if he began receiving EN within the first
hour of hospitalization. Impact with Glutamine is 24% protein, so JA would receive a maximum
of 93.6 g of protein in the first day of hospitalization. Based on the fluid order, the patient was
started on fluid resuscitation using Lactated Ringers at 610 mL/hr for the first eight hours and
then decreased to 305 mL/hr for the next 16 hours. However, JA had a total fluid intake of
16,425 mL and an output of 1,696 mL (1,295 mL from urine, which is approximately 18 mL/hr).
According to the Parkland formula, the patient needs 11.4 L of fluid within the first 24 hours


following a burn injury, with 5.7 L administered in the first eight hours. He met these goals
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based on the intake/output report.

Medical Nutrition Therapy Plan:
Based on the patients intake/output record, the care team initiated enteral feeding within
the first 16 hours of hospitalization, likely in hour 8 and 9 if the rate of administration from the
physicians orders was closely followed. Moving forward, he will need to advance to 2,700 2,900 kcal/day to meet caloric requirements based on Xie and Zawacki equations. If the patient
still needs be administered Propofol, his calorie intake from enteral nutrition can be reduced by
approximately 650 calories. He will also need to receive the recommended 1.5-2.0 g of protein
per kilogram of body weight, as his current protein intake is much less. The care team also
ordered that the patient receive a multivitamin as well as additional micronutrients to promote
wound healing, such as Vitamin C, zinc, thiamin, and folate.
Theoretical Discussion of Disease Processes
At temperatures greater than 111F, proteins lose their three-dimensional shape and break
down, resulting in tissue damage. Burns may cause disruptions in skin sensation as well as the
skins ability to prevent water loss through evaporation. Burns may also affect the bodys ability
to control body temperature. When burns disrupt cell membranes, a loss of potassium in the
spaces outside the cells and an inability to take up water and sodium may occur, resulting in
hyperkalemia.
In large burns (over 30 percent of the total body surface), there is an inflammatory
response, which increases fluid leakage in capillaries and causes edema. Overall blood volume is
lost and the remaining blood suffers significant plasma loss, making the blood more


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concentrated. This may cause poor blood flow to the kidneys and ultimately result in renal failure
or stomach ulcers. Respiratory changes may also occur when inflammatory mediators initiate
bronchoconstriction, resulting in respiratory distress. In addition, an inflammatory response for
severe burns may cause cardiovascular changes. The capillary permeability increases, leading to
loss of intravascular proteins and fluids. Vasoconstriction occurs in the peripheral (outer parts of
the body) and splanchnic (abdominal) regions. Myocardial (muscles of the heart) contraction
also decreases, due to tumor necrosis factor . These cardiovascular changes, coupled with fluid
loss from the burn wound, may result in systemic hypotension (low blood pressure) and end
organ hypoperfusion (decreased blood flow).
The inflammatory response may also cause metabolic changes. The basal metabolic rate
increases up to three times its original rate. Also, splanchnic hypoperfusion makes it necessary to
administer enteral feeding to decrease catabolism and maintain gut integrity (Nelms, Sucher, &
Lacey, 2016). Increased levels of catecholamines and cortisol can result in a hypermetabolic
state, which includes an increased cardiac output, increased metabolism, fast heart rate, and poor
immune function.
Pertinent Lab Findings
Hyperkalemia occurs because potassium is the most abundant ion inside the cell. During
a burn, cells are damaged and potassium leaves the cell and enters the blood, so serum potassium
increased. In addition, high protein losses from wounds and the overall acute inflammatory
response can affect accurate interpretation of the protein markers albumin, prealbumin, and Creactive protein in relationship to nutritional status (Nelms, Sucher, & Lacey, 2016).


Diagnostic Tests/Procedures
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Energy requirements are measured by indirect calorimetry or estimated using standard

equations. The Curreri equation is a specialized equation developed for use in burn patients that
incorporates the extent of a burn injury. This equation best estimates energy requirements at the
peak of burn injury and calculations do not necessarily accommodate the changes that occur
from day to day.
Burns can be classified by depth, extent, and associated injuries. The most commonly
used classification is based on depth, determined by an examination as well as a biopsy. It may
be difficult to accurately determine depth the first time, so the examination is repeated over a few
days as necessary. In those who have headaches, dizziness, and a fire-related burn, carbon
monoxide poisoning and cyanide poisoning should considered as potential complications.
The size of a burn is measured as a percentage of total body surface area affected by
partial thickness or full thickness (third-degree) burns. First-degree burns are not included in this
estimation. Most burns involve less than 10 percent of total body surface area. The Wallace rule
of nines, the Lund and Browder chart, and estimations based on a persons palm size, are used to
determine total body surface area. Lund and Browder charts are more accurate because they take
into consideration different proportions of body parts in adults and children. (Nelms, Sucher, &
Lacey, 2016).
People with extensive burns should be wrapped in clean sheets until they arrive at a
hospital. Since burn wounds are prone to infection, a tetanus booster shot should be given if an
individual has not been immunized within the last five years. Hyperbaric oxygenation ( medical

use of oxygen at a level higher than atmospheric pressure) may be useful in addition to
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traditional treatments (American Burn Association Medication, 2014).

The most severe burn injuries require nutrition support or a substitute for an oral diet.
Early enteral feeding is recommended during metabolic stress and for those who are critically ill.
Enteral nutrition that is initiated within 24 hours of injury has been associated with preventing
infections and Curlings ulcer, and reducing protein catabolism (Nelms, Sucher, & Lacey, 2016).
The enteral feeding prescription for a burn patient will need to accommodate the special
metabolic requirements of this stressed state. In severe burn patients, ileus (paralysis of the GI
tract) is common during the burn shock period, but enteral feeding is generally tolerated when
delivered to the small bowel. High-protein formulas with supplemental glutamine, amino acids,
and omega-3 fatty acids may also be beneficial. Parenteral nutrition (PN) can be prescribed in
combination with enteral feeding or oral intake, or for complete nutrition, if the patient is unable
to meet their increased needs.
Common Medical / Surgical / Dietary Treatment
Wounds may require surgical closure with skin grafts or flaps. A skin graft is a patch of
skin that is removed by surgery from one area of the body and transplanted or attached to another
area. Healthy skin is taken from a site in the body called the donor site and the healthy skin,
called a graft, is carefully spread on the bare area where it is being transplanted. Third-degree
circumferential burns that extend around the limbs or chest may need urgent surgical release of
the skin, called an escharotomy, in order to prevent problems with distal circulation or
ventilation. In a third-degree burn, the epidermis and dermis are destroyed along with sensory
nerves in the dermis, leaving a tough leathery tissue. The underlying tissues are then rehydrated


and become constricted due to the loss of elasticity, leading to impaired circulation. An
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escharotomy can relieve pressure, improve circulation, and reduce the likelihood of burn-induced
compartment syndrome, which is increased pressure within a closed anatomical space caused by
compromised circulation (Burn Wound Infections Medication, 2014).
Fasciotomies may be required for electrical burns. It is a limb-saving surgical procedure
where the fascia is cut to relieve tension or pressure to treat the resulting loss of circulation to an
area of tissue or muscle. Fasciotomies are also used to treat acute compartment syndrome,
particularly in the legs or arms of burn victims.
Nutrient supplementation may be necessary for burns. According to Nelms, Sucher, &
Lacey (2016), glutamine may be supplemented at a rate of 0.3-0.5 g/kg/day for 10 g doses via a
feeding tube. Zinc may be supplemented in full thickness wounds encompassing over 20 percent
TBSA. Zinc can be intravenously in 30 mg increments five times per day and then 50 mg daily
by mouth or feeding tube. Selenium may be supplemented in full-thickness wounds over 20
percent TBSA where the patient is intubated or if wounds encompass more than over 30%
TBSA. Selenium may be supplemented 1000 g/day intravenously for 14 days and then 200 g
twice daily by mouth or feeding tube. Vitamin C may be supplemented for full-thickness burns
over 20 percent TBSA in dosages of about 500 mg/day twice daily by mouth or feeding tube.
Vitamin E may also be necessary in 400 unit increments twice daily by mouth or feeding tube.
Common Prescriptions
Burns are very painful and many different options are used for pain management
including analgesics, such as ibuprofen and acetaminophen, and opioids such as morphine.
Those with intense burns are given antibiotic drugs intravenously. Administering recombinant


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human growth hormone in those with burns that involve more than 40% of their body appears to
speed healing by increasing protein synthesis.
Common prescriptions for patients with severe burns include:
Recombinant human growth hormone (rhGH), which is a peptide hormone used to
stimulate cell reproduction and regeneration. The use of rhGH requires regular
monitoring due to the frequency and severity of side effects, including joint swelling and
joint pain.
Mafenide Acetate, which is a topical antibiotic prescribed for second and third-degree
burns that is applied to the affected area once or twice daily.
Silver Sulfadiazine, which is classified as a miscellaneous dermatological. This
medication is a sulfonamide and is prescribed for preventing bacterial infection in second
and third-degree burns. It can kill bacteria by targeting the cell membrane and cell wall.
It is a topical cream and can be applied once or twice daily to a thickness of
approximately 1/16 inch.
Evaluation of Specific Patients Course of Illness
JA has a 40 percent TBSA burn, meaning it is severe. His bandages are changed daily
and he is expected to undergo skin grafting. He is experiencing respiratory failure, so a
bronchoscopy is scheduled. As discussed earlier, respiratory changes may also occur when
inflammatory mediators initiate bronchoconstriction, resulting in respiratory distress syndrome in
severely burned adults. A bronchoscopy would be necessary to determine the severity of
respiratory failure.

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Treatment using methadone is being increased to 10 mg every eight hours. Methadone is
commonly used to wean people off opioid medication. The patient is being weaned off Propofol,
an intravenously delivered amnestic agent. Pain medication is a common among burn patients.
The patient is experiencing hyperkalemia but is improving. The reason hyperkalemia
occurs, according to American Burn Association Medication (2014), is because during a burn,
cells are damaged and potassium leaves the cell to go into the blood. The finding upon lab
drawings is hyperkalemia.
Continual fluid resuscitation is being administered for acute kidney injury of the patient.
As discussed earlier about the pathophysiology of the disease, blood volume is lost and the blood
becomes more concentrated, resulting in poor blood flow to the kidneys. Continual fluid
resuscitation is necessary for JA.
Final Nutrition Care Plan
JA is a 65 y.o. male, who is 72 inches tall (1.8 m) and weights 157 lbs. (71.2 kg). His
BMI is normal, at 21.3 kg/m2. His IBW is 178 lbs. (80.9 kg), making him 88% of ideal body
weight. JA has experienced no recent body weight changes in the past 6 months; his weight is
normal. JAs albumin is very low at 2.1 g/dL, indicating inflammation, and his total lymphocyte
count is very high at 18.1*103/mm3. High total lymphocyte count indicates infection.
Nutrition Diagnoses
1. Inadequate protein-energy intake R/T increased protein and energy needs due to severe
burn and altered kidney function AEB lab values indicating low serum protein and
albumin levels.

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2. Excessive fluid intake R/T administration of excessive IV fluid in addition to enteral
feeding totaling 16.4 L of fluid in 24 hours AEB fluid intake of 230.7 mL/kg and output
of 23.8 mL/kg, indicating oliguria.
3. Altered nutrition-related lab values R/T catabolic response to injury, altered kidney
function, and metabolic acidosis AEB low blood pH, low serum bicarbonate,
hyperkalemia, hyperglycemia, hypocalcemia, hyperchloremia, hypomagnesemia, low
albumin, and very high levels of C-reactive protein.
Diet History
JA has been diagnosed with diabetes mellitus (DM), hypertension (high blood pressure;
HTN) and gastroesophageal reflux disorder (GERD). He has not been following any specific diet
and has had a stable weight for the last six months. He has not been monitoring his blood glucose
levels for about a year. JA has smoked a pack of cigarettes every day for 30 years, which may
impact his taste and smell capabilities. JA is currently intubated and receiving nutrition via EN.
Evaluation of Lab Findings
Sodium: 137 mEq/L (Within Normal Limits)
Phosphate: 3.4 mg/dL (Within Normal Limits)
Potassium: 5.9 mEq/L
The patient is experiencing hyperkalemia due to burn and tissue damage, secondary to
metabolic acidosis. In the physicians notes, he indicated that the hyperkalemia was
improving and the aim was to continue to resuscitate with Lactated Ringers.
Chloride: 113 mEq/L
Chloride can increase in metabolic acidosis and renal insufficiency, as our


patient is experiencing.
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Magnesium: 1.5 mg/dL

Magnesium can become scarce in malnutrition.
Calcium: 6.9 mg/dL
Calcium could be low due to renal dysfunction. Overall, these electrolyte lab values are
indicative of a patient in metabolic stress.
CO2: 20 mEq/L
pH: 7.31
HCO3-: 19.6 mEq/L
These values show that the patient is in metabolic acidosis, with low bicarbonate and low
CO2. Although the ventilation is successfully eliminating carbon dioxide from the lungs,
the kidneys are still working to maintain blood acid/base balance.
pCO2: 39.8 mm Hg (Within Normal Limits)
SO2: 99.8% (Within Normal Limits)
pO2: 106.5 mm Hg (Within Normal Limits)
These lab findings show that the intubation and ventilation of the patient is adequate to
maintain levels of oxygen, carbon dioxide, and oxygen saturation.
BUN: 13 mg/dL (Within Normal Limits)
BUN/Crea ratio: 10:3 (Within Normal Limits)
Glucose: 211 mg/dL
The patients glucose is possibly elevated due to unmanaged diabetes mellitus (DM),


stress, and the burn injury.
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Osmolality: 295 mmol/kg/H2O (Within Normal Limits)

The patient is adequately hydrated.
Bilirubin total: 1.2 mg/dL
Bilirubin direct: 0.2 mg/dL (Within Normal Limits)
The patient has normal hemoglobin breakdown, although total bilirubin is slightly higher
than normal.
Protein, total: 4.7 g/dL
The protein concentration usually represents albumin and globulin, and can be a good
marker for malnutrition, but only in a non-traumatic state. Since our patient is
experiencing inflammation, total protein concentration does not tell us much, except that
albumin and globulin levels are low.
Albumin: 2.1 g/dL
Low albumin levels are typically seen in patients with severe burns.
Prealbumin: 12 mg/dL
Prealbumin is a very sensitive marker for the stress response. This patients lab values
show acute stress response to injury.
Alkaline phosphatase: 70 U/L (Within Normal Limits)
Normal levels of alkaline phosphatase indicate that gallbladder function is fine.
ALT: 21 U/L (Within Normal Limits)

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Normal levels of alanine aminotransferase indicate that liver cells are not damaged. Since
liver function is still normal, drugs can be administered with low risk of toxicity.
AST: 44 U/L
Aspartate aminotransferase is an enzyme found in the liver, cardiac and skeletal muscle,
brain, pancreas, kidney, and other tissues. It increases with liver, kidney and burn injury.
C-reactive protein: 12 mg/dL
C-reactive protein is a general marker of inflammation. The patients CRP is elevated,
indicating inflammation.
Creatinine serum: 1.26 mg/dL
This value is slightly higher than normal, which indicates slightly higher than normal
skeletal muscle metabolism.
PT: 13.7 sec (Within Normal Limits)
PTT: 26 sec (Within Normal Limits)
These labs represent the patients tendency to bleed. Since these labs are within normal
limits, the patient is not expected to bleed abnormally, and does not need vitamin K. If
they were abnormal, the RD might suggest vitamin K supplementation.
WBC: 18.1 x103/mm3
RBC: 5.97 x 106/mm3 (Within Normal Limits)
Hemoglobin: 18.7 Hgb, g/dL (Within Normal Limits)
Hematocrit: 54.4% Hct (Within Normal Limits)
While the patients RBC, Hb, and Hct are normal, his white blood cell count is slightly


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elevated, which could indicate an infection or response to stress. WBCs also increase in
metabolic acidosis and burns (Escott-Stump, 2015).
Review of Medications and Food/Nutrient Interactions
Ascorbic acid is vitamin C. There are no side effects at a dosage of 1,000 mg/day.
Famotidine is a H2 receptor antagonist. A bland diet may be recommended. The patient
should take magnesium and iron supplements at least two hours before or after
Famotidine. Those taking this medication should avoid alcohol, limit caffeine, and avoid
or limit smoking.
Heparin is an anticoagulant and can cause nausea, vomiting, bleeding, hemorrhage,
dizziness, headache, and bruising. Heparin contains sodium and should not be used in
patients experiencing renal dysfunction or hyperkalemia.
Insulin is a hormone replacement for treatment of DM. Insulin interacts with alcohol, so
the patient should abstain from drinking alcohol if he is still receiving insulin after
leaving the hospital. Insulin was administered to JA to counteract the increased
endogenous production of glucose due to thermal injury (Escott-Stump, 2015).
A multivitamin can cause nausea and vomiting, but no severe side effects.
Zinc sulfate is a mineral supplement. The patient should take this supplement one hour
before or two hours after meals. If gastrointestinal upset occurs, take the supplement with
food. Zinc should not be taken with copper, iron, or calcium supplements.
Methadone is an analgesic, opioid, and narcotic. Patients taking methadone should avoid
grapefruit and related citrus, St. Johns Wort, and alcohol. Methadone may be habitforming.


Oxandrolone is an anabolic steroid used to promote weight gain after trauma. It will
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increase appetite, weight, and lean body mass. The patient must consume adequate
calcium and protein to support an anabolic effect.
Oxycodone is an analgesic that may become habit-forming. Patient should take it with
food or milk to decrease GI distress. It should not be administered through a feeding tube,
as it may clog the tube. Oxycodone should not be consumed with grapefruit or other
citrus. Side effects may include anorexia, drowsiness, and sedation.
Senna is a laxative that should be taken with 8 oz. of water or juice. The patient must
consume adequate fiber and at least 1.5-2.0 L of fluid daily.
Docusate is a stool softener and laxative. The liquid can be mixed with 8 oz. of milk or
juice to disguise the taste and prevent throat irritation. The patient must consume
adequate fiber and at least 1.5-2.0 L of fluid daily.
Acetaminophen is a generic name for Tylenol. JA is allergic to this drug and should not
be receiving it.
Midazolam HCl is a sedative and anesthesia adjunct. It should be taken with food to
decrease GI distress. Patients taking this medication should avoid grapefruit, sedative
herbs like kava and chamomile, and stimulants like caffeine, guarana, or yerba mate.
Hydromorphone is an analgesic, antitussive narcotic. It can be taken with food to reduce
GI distress. The patient must consume adequate fluids to remain hydrated, but avoid
alcohol. This medicine may be habit-forming with long-term use.

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Fentanyl is an analgesic and narcotic. It may cause dry mouth, dyspepsia, and nausea or
vomiting. Patients taking fentanyl should avoid alcohol. This medication should be used
cautiously with patients experiencing low hepatic and renal function.
Propofol is an anesthetic and sedative used in intubated adults. Propofol is made of 10%
soy oil, so a low-fat enteral feeding should be used to compensate for the lipid intake
with the drug, or health care providers should account for the lipid-based calories from
Propofol in daily intake.
Thiamin is a B vitamin with few side effects. Thiamin may be deficient in alcohol users,
so our patient could benefit from this supplement.
Folate is a B vitamin with few side effects. It is used to treat depression and
megaloblastic anemia.
Ketamine is used to produce loss of consciousness from patients undergoing medical
procedures (Pronsky & Crowe, 2012).
Evaluation of Physical and Clinical Findings
Physical findings include 40 percent total burn surface area, which affects JAs calorie
and protein needs as well as electrolyte balance and hydration needs, as discussed earlier in this
paper. Smoke inhalation injury led to intubation for respiratory support, which affected JAs
ability to eat orally. Since bowel sounds were present, JA received a tube feed placement and EN
(enteral nutrition). Major clinical findings are metabolic acidosis, acute kidney injury, and
respiratory distress. Continual fluid resuscitation with Lactated Ringers to restore electrolyte
balance and intubation are necessary to treat kidney injury, acidosis, and edema in the lungs.
Energy Requirements


25

JAs EER is 2,800 kcal based on the Xie and Zawacki equations that were developed
specifically for burn patients.
Xie equation:
kcal/day = [1000 x body surface area] + [25 x burned surface area (% TBSA)]
= (1000 * 1.90 m2) + (25 * 40%) = 1900 + 10
= 2,900 kcal/day (40.7 kcal/kg/day)
Zawacki equation: 1440 kcal/m^2/day
= 1440 kcal / 1.90 m2
= 2,736 kcals/day, (38 kcals/kg/day)
Protein Requirements
EPR: 140 g (Based on 2.0 g/kg/day for patients with burn/acute kidney injury, cross referenced
with Xie recommendation)
Protein needs calculations:
EPR = 2 g/kg * 71.2 kg = 142.4 g
Xie equation for protein needs:
EPR = (0.15 * 2800) to (0.20* 2800) = 420 to 560 kcals / 4 kcal/g = 105-140 g
Diet Order
The physician ordered enteral feeding through a nasogastric tube. The feeding would
begin with 20 mL/hr of Impact with Glutamine for the first four hours after initiating tube
feeding, then advance by 20 mL/hr every four hours until reaching a goal rate of 60 mL/hr.
Based on the diet order, JA should be receiving 2,220 kcal per day from enteral nutrition and
Propofol if he begins feeding in the first hour after hospitalization. He should be receiving 374.4


26

kcal (93.6 g) of protein, 717.6 (179.4 g) from carbohydrates, and 1,128 kcal (125.3 g) of fat. It
would be rare for tube feeding to be initiated immediately after hospitalization, especially after a
severe trauma, but it should be started within the first 24 hours of hospitalization.
The physician also ordered 610 mL/hr of Lactated Ringers (LR) solution for the first
eight hours of hospitalization and 305 mL/hr for the next 16 hours. This would provide JA with
9,760 mL of LR for the first 24 hours of hospitalization. When combined with the 1,200 mL of
fluid that would be administered to JA if he began receiving tube feeding within the first hour of
hospitalization, the orders would provide JA with 10,960 mL of fluid.
Calculations (Diet Order):
Total kcals (based on diet order)
Impact with Glutamine = 1.3 kcal/mL
Hours 0-4 = 20 mL/hr x 4 hrs = 80 mL
= 1200 mL x 1.3 kcal/mL = 1,560 kcal
Propofol = 1.1 kcal/mL
Currently receiving 25 mL/hr
25 mL/hr x 24 hours = 600 mL x 1.1 kcal/mL = 660 kcal
= 1,560 + 660 = 2,220 kcal total
Total protein (based on diet order)
Impact with Glutamine = 24% protein
= 1560 kcal x 0.24 = 374.4 kcal from protein


= 374.4 kcal / 4 kcal/g = 93.6 g of protein
Total carbohydrates (based on diet order)
Impact with Glutamine = 46% carbohydrates
= 1560 kcal x 0.46 = 717.6 kcal from carbohydrates
= 717.6 kcal / 4 kcal/g = 179.4 g of carbohydrates
Total fat (based on diet order)
Impact with Glutamine = 30% fat
= 1560 kcal x 0.3 = 468 kcal from fat
= 468 kcal / 9 kcal/g = 52 g of fat
= 25 mL/hr x 24 hours = 600 mL x 1.1 kcal/mL = 660 kcal from fat
= 660 kcal / 9 kcal/g = 73.3 g of fat
TOTAL = 468 + 660 = 1,128 kcal (125.3 g) from fat
Total fluid (based on MDs order)
Lactated Ringers
= (8 hrs. x 610 mL/hr) + (16 hrs. x 305 mL/hr) = 9,760 mL
Enteral Nutrition = 1,200 mL (as calculated above)
TOTAL = 9,760 mL + 1,200 mL = 10,960 mL
27

Table 1. Intake/Output Table for JAs first 24 hours of hospitalization.
28

However, the physicians order was not properly followed, as evidenced in the
intake/output record (Table 1). JA only received 1,395 kcal in the first 24 hours of
hospitalization, 735 kcal of which were from Impact with Glutamine and 660 kcal of which were
from Propofol. Based on the 735 kcal from enteral formula, JA received 44.1g of protein, which
is drastically less than the MDs diet order. JA began receiving enteral nutrition early on in his
hospitalization (in hours 8-16). During hours 8-16, he received 228 mL of enteral formula, so it
is likely that he began receiving enteral formula during hour 8 or 9 if the feeding was advanced
from 20 mL/hr to 40 mL/hr after four hours. However, the rate did not advance to 60 mL/hr in
the following 8 hours (hours 16-24), per the physicians orders, because JA only received 42.1
mL/hr in this 8-hour period (totaling 337 mL). Even if he received 40 mL/hr for the first 2 hours
of this timeframe and 60 mL/hr for the remaining 6 hours, his total intake would be more than is
indicated on the intake/output record, as evidenced in Table 2. So, it is clear that his diet orders
were not followed closely. Although the continuous IV fluid rates closely followed the


29

physicians orders, JA was also administered additional fluids via IV bolus and IV piggyback.
This caused his total fluid intake to far exceed the physicians orders.
Calculations:
Energy intake (based on actual intake):
565 mL intake x 1.3 kcal/mL
= 735 kcal from Impact with Glutamine
= 735 kcal + 660 kcal (from Propofol)
= 1,395 kcal total
Protein intake (based on actual intake):
= First day kcal (735 kcal from Impact Glutamine) x 0.24 = 176.4 kcal of protein
= 176.4 / 4 kcal/g = 44.1 g protein
Table 2. Comparison of Diet Order (if initiated in Hour 8) and Actual Intake for JAs first 24
hours of hospitalization.

Diet Therapy
Goals for nutrition therapy in a patient with severe burns include:
Restoring fluid and electrolyte balance to replace deficits, prevent complications from the
injury, and address renal insufficiency (Escott-Stump, 2015); and


30

Providing early enteral feeding to meet a high-calorie, high-protein diet to address the
hypermetabolic response and catabolism associated with severe burns, and promote
wound healing while conserving lean body mass. (Escott-Stump, 2015)
JAs diet order is insufficient in total energy and protein for a patient with a severe burn,
even if tube feeding was followed properly and it was administered during the first hour of
hospitalization. The physicians fluid order for JA was slightly less than his estimated fluid needs
based on the Parkland formula. Although the rate ordered would provide nearly half of the total
fluid order within the first eight hours, as recommended by the Parkland formula, the actual fluid
intake far exceeded orders and estimated fluid needs, as evidenced in Table 3 below.
Table 3. Comparison of Fluid Order, Fluid Needs, and Actual Intake for JAs first 24 hours of
hospitalization.

We would recommend increasing the administration rate of Impact with Glutamine to 75
mL/hr to satisfy JAs kcal and protein needs during the next 24 hours while he is being weaned


31

off Propofol. JA is currently administered Propofol at 25 mL/hr and the physician is hoping to
wean the patient off the medicine by the end of the day, but depending on the rate of weaning the
patient off the medicine, he still may receive approximately 350-500 kcal from the Propofol. The
75 mL/hr rate accounts for additional energy provided by the Propofol and ensures the patient
receives nearly 2 g protein per kilogram of body weight. We would then supplement the tube
feeding by administering Lactated Ringers solution at 42 mL/hr to meet JAs fluid needs. A
sample intake table for the next 24 hours is in Table 4 below. After JA is no longer receiving
Propofol (which will be accomplished in the next 24 hours), we recommend changing the EN
formula to a high-protein renal formula, like Nestles NOVASOURCE Renal, so he will receive
sufficient energy and protein for his increased needs.
Table 4. Proposed Intake Table for JAs next 24 hours of hospitalization.
Nutritional Goals
Short-term goals for JAs nutrition therapy include:
1. The patient will consume at least 2,800 kcal, 140 g of protein, and 2.8 L of fluid in the
next 24 hours. These energy and protein needs will be achieved through administration of
75 mL/hr of Impact with Glutamine in addition to Propofol, off of which the patient will

32

be weaned in the next 24 hours. JA will also receive approximately 42 mL/hr of Lactated
Ringers solution, totaling 1,008 mL from IV solution.
2. The patient will receive alternatives to acetaminophen, heparin, and famotidine within 24
hours to decrease the likelihood of negative complications.
3. The patients serum protein and albumin will increase, getting closer to normal ranges
(greater than 6 g/dL and 4 g/dL, respectively) within 24 hours. This will be achieved by
increasing JAs protein intake to an appropriate level for his condition.
4. The patients blood potassium levels will decrease, getting closer to normal range (3.55.0 mEq/L) within 24 hours. This will be achieved by not only adjusting JAs energy,
protein, and fluid intake to an appropriate level for his condition, but also by removing
him from medications that affect his acute kidney injury.
5. The patients lab values for C-reactive protein will decrease, getting closer to normal
range (less than 8.0 mg/dL) within 24 hours. This will be achieved by not only removing
JA from the medication he is allergic to, but also by adjusting JAs energy, protein, and
fluid intake to an appropriate level for his condition.
Long-term goals for JAs nutrition therapy include:
1. After JA is weaned off Propofol re-evaluate the EN formula administered to JA to ensure
he is receiving adequate protein without receiving too many calories. Although JA does
need to receive a high-energy, high-protein diet, the ratio of calories-to-protein in Impact
with Glutamine may not be ideal. A proper diet will be achieved by switching JA to a
high-protein formula.

33

2. By the time JA is discharged from the hospital, his serum protein and albumin levels will
be within normal ranges. This will be achieved through consistent enteral feeding and
daily monitoring of his intake, output, and lab values to assess necessary changes to his
diet order.
3. By the time JA is discharged from the hospital, the vast majority of his lab values for
blood pH, electrolytes (potassium, sodium, chloride), and inflammation markers (Creactive protein and prealbumin) will near normal ranges. This will be achieved through
consistent fluid administration and enteral feeding, with continuous monitoring of his
intake, output, and lab values to assess any needed changes to his diet order.
4. By the time JA is discharged from the hospital, he will demonstrate knowledge of
consuming a high-protein, high-energy diet, which is needed for effective wound healing.
This will be achieved through patient counseling on the need for this diet and patient
education materials that he can take home with him.
5. By the time JA is discharged from the hospital, he will be referred to an outpatient
dietitian to assist him with not only structuring a diet for wound healing, but also learning
techniques to control his diabetes and hypertension.
ADIME Note

Assessment:

JA is a 65 year-old Caucasian male who was admitted to the surgical intensive care unit as a
level 2 trauma patient with serious burns covering 40% of his body. He may have also incurred
injuries from smoke inhalation. JA was involved in a trailer fire during which his clothes caught
fire while trying to extinguish an engine fire. He states that he has smoked 1 PPD for more than
30 years and consumes at least 2-3 beers per day.

65 y.o. male


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Dx: serious burns on 40% of body, respiratory failure, acute pain due to injury, oliguria, acute
kidney injury, and malnutrition
PMH: Diabetes, Hypertension, GERD, cholecystectomy (1985)
Medications: N/A
MD Diet Order: NPO
Allergies: Tylenol
Ht. 6 (1.83 m), Wt. 157 lbs. (71.2 kg)

Labs:
Temperature: 100F
BP: 140/93 mmHg (High)
Pulse: 120 bpm (High)
SpO2: 98% (Within normal limits)
Sodium: 137 mEq/L (Within normal limits)
Potassium: 5.9 mEq/L (High)
Chloride: 113 mEq/L (High)
CO2: 20 mEq/L (Low)
BUN: 13 mg/dL (Within normal limits)
Creatinine serum: 1.26 mg/dL (High)
BUN/Crea ratio: 10.3 (Within normal limits)
Glucose: 211 mg/dL (High)
Phosphate: 3.4 mg/dL (Within normal limits)
Magnesium: 1.5 mg/dL (Low)
Calcium: 6.9 mg/dL (Low)
Osmolality: 295 mmol/kg/H2O (Within normal limits)
Bilirubin total: 1.2 mg/dL (Within normal limits)
Bilirubin direct: 0.2 mg/dL (Within normal limits)
Protein, total: 4.7 g/dL (Low)
Albumin: 2.1 g/dL (Low)
Prealbumin: 12 mg/dL (Low)
Alkaline phosphatase: 70 U/L (Within normal limits)
ALT: 21 U/L (Within normal limits)
AST: 44 U/L (High)
C-reactive protein: 12 mg/dL (High)
PT: 13.7 sec (Within normal limits)
PTT: 26 sec (Within normal limits)
WBC: 18.1 x103/mm3 (High)
RBC: 5.97 x 106/mm3 (Within normal limits)
Hemoglobin: 18.7 Hgb, g/dL (Within normal limits)
Hematocrit: 54.4% Hct (Within normal limits)
pH: 7.31 (Low)
pCO2: 39.8 mm Hg (Within normal limits)
SO2: 99.8% (Within normal limits)


35

pO2: 106.5 mm Hg (Within normal limits)
HCO3-: 19.6 mEq/L (Low)

EER: 2,800 kcal (Based on Xie and Zawacki equations)
EPR: 140 g (Based on 2.0 g/kg/day for patients with burn/acute kidney injury, cross referenced
with Xie recommendation)
Fluid needs: 11.4 L in the first 24 hours, of which 5.7 L is administered within the first 8
hours (based on Parkland formula); and 2.8 L after the first 24 hours (based on 1
mL/kcal)
BMI: 21.3 kg/m2 (Normal)
IBW: 178 lbs. (80.9 kg)
%IBW: 88%
Body Surface Area: 1.9 m2

Medication Interactions:
The patient is allergic to Tylenol and should not be administered acetaminophen.
Heparin contains sodium and should not be used in patients experiencing renal
dysfunction or hyperkalemia.
Famotidine should not be used in patients experiencing renal dysfunction.
Famotidine interacts with nicotine so the patient should abstain from smoking if he is still
taking this medication after he leaves the hospital.
Insulin and methadone interact with alcohol so the patient should abstain from drinking
alcohol if he is still taking one or both of these medications after he leaves the hospital.

Diagnosis:

1. Inadequate protein-energy intake R/T increased protein and energy needs due to severe burn
and altered kidney function AEB lab values indicating low serum protein and albumin levels.

2. Excessive fluid intake R/T administration of excessive IV fluid in addition to enteral feeding
totaling 16.4 L of fluid in 24 hours AEB fluid intake of 230.7 mL/kg and output of 23.8 mL/kg,
indicating oliguria.

3. Altered nutrition-related lab values R/T catabolic response to injury, altered kidney function,
and metabolic acidosis AEB low blood pH, low serum bicarbonate, hyperkalemia,
hyperglycemia, hypocalcemia, hyperchloremia, hypomagnesemia, low albumin, and very high
levels of C-reactive protein.

Intervention:

1. Recommended that the patients intake of Impact with Glutamine formula via enteral nutrition
increase to 75 mL/hr, totaling 2,340 kcal per day and 140 g of protein.


36

2. Discussed with the physician and/or pharmacist that the patient receive alternatives to
acetaminophen, heparin, and famotidine to decrease likelihood of negative complications.

3. Recommended that the patients fluid intake decrease to 42 mL/hr to supplement enteral
feeding and avoid overhydration.

4. Continued monitoring lab tests for changes in electrolytes and inflammation markers as
medications, enteral nutrition, and fluid intake are adjusted.

Monitoring/Evaluation:

1. The patients intake will be monitored to ensure he is consuming at least 2,800 kcal, 140 g of
protein, and 2.8 L of fluid per day prior to discharge.

2. The patients serum albumin will increase, nearing normal range (greater than 4 g/dL).

4. The patients blood potassium levels will decrease, nearing normal range (3.5-5.0 mEq/L).

4. The patients lab values for C-reactive protein will decrease, nearing normal range (less than
8.0 mg/dL).

Reassess needs based on laboratory tests within 24 hours.

Signatures:

Alyssa Snow Callahan, Sarah Pruett Soufl, Cory Ruth, Tallenee Hacatoryan, Meghry Achekian

_______________ _______________ ______________ ______________ ______________

Student dietitians

Case Study Questions
1) Describe how burn wounds are classified. Identify and describe Mr. Angelos burn injuries.


Superficial burns affect the epidermis (outermost layer of skin) and are caused by
37
ultraviolet light or a very short exposure to a flame or heat. Superficial burns appear on the skin
as dry and red marks that blanch with pressure. The sensation of these burns can be painful,
taking up to 3-6 days to heal. Superficial burns do not scar.
Slightly more severe, superficial partial-thickness burns affect both the epidermis and the
dermis layers of the skin. These burns can be caused by scalding the skin or exposure to a short
flash of heat. They appear blistered, moist, red, and weeping, and blanch with pressure. The
sensation of these burns can be painful to both air and temperatures, taking 7-20 days to fully
heal. Most partial-thickness burns do not scar, but they do have potential to cause minor pigment
changes. Deep partial-thickness burns also affect the epidermis and dermis and are caused by
scalding, flame, oil, or grease. These burns appear blistery, wet, waxy dry, and of varying
colors, but do not blanch with pressure. A painful sensation is felt only with pressure. These
burns take more than 21 days to heal, and cause severe scarring with a high risk of contracture
(permanent shortening of a joint or muscle).
Full-thickness burns can be caused by scalding, flame, steam, oil, grease, chemicals, or highvoltage electricity. These burns appear waxy-white to leathery-gray to charred-black. The burned
skin appears dry and inelastic, and it does not blanch with pressure. The painful sensation caused
by these burns is deep when pressure is applied. These burns may never fully heal if the burns
affect more than two percent of the bodys total surface area, and the scarring is very severe with
high risk of contracture. Since JAs burn injuries require skin grafting and encompass 40 percent
of his total body surface area, thus they are classified as full-thickness burns.

38

The American Burn Association classify burns as minor, moderate, and major burns.
Minor burns cover less than 10 percent of the total body surface area (TBSA), while moderate
burns cover 10-20 percent TBSA, and major burns affect more than 20 percent TBSA. At 40
percent of his TBSA, JAs burns would be classified as major.
2) Explain the rule of nines used in assessment of burn injury.
According to Nelms, Sucher, & Lacey (2016) the rule of nines classifies the parts of the
body in terms of total body surface area to estimate the body surface area affected by burns. The
head and neck both account for nine percent TBSA, the torso accounts for 36 percent, the arms
account for 18 percent (nine percent each), the legs account for 36 percent (18 percent each), and
the peritoneum accounts for the remaining one percent. These percentages are further broken
down based on how much of the body part is affected. For instance, a lower leg accounts for nine
percent and the back of a lower leg accounts for 4.5 percent.
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 patients for fluid
resuscitation? What are the components of this solution?
Fluid resuscitation replenishes bodily fluid lost due to a burn or any fluid shifts. Fluids
can be replaced with intravenous therapy. Lactated Ringers is a hypotonic solution often used in
those who have significant burns. It includes lactate, sodium chloride, potassium chloride,
calcium chloride, and sodium bicarbonate.
The Parkland formula is used to determine the volume of intravenous fluids required by a
patient with severe burns during the first 24 hours post-injury to maintain blood stability. The


39

formula is based on the affected individuals TBSA and weight. The formula also states that half
of the fluid should be administered over the first eight hours following the injury and the
remaining half is administered over the following 16 hours (Parkland Formula, 2015).
JAs fluid needs for the first 24 hours:
Volume of fluid needed (V) = 4 mass of patient (in kg) %TBSA burned 100
= 4 71.2 kg 40% 100
= 11,392 mL = 11.4 L of water (within first 24 hours), with 5.7 L (within first 8 hours)
4) What is inhalation injury? How can it affect patient management?
Smoke inhalation causes most fire-related deaths and produces injury through several
mechanisms, including thermal injury to the upper airway, as well as irritation or chemical injury
to the airways from soot, asphyxiation, or toxicity from carbon monoxide and other gases, like
cyanide (Nelms, Sucher, & Lacey, 2016). Respiratory distress responds to aggressive initial
management, but initial lab results showing normal blood test results can give a healthcare
provider a false reading of the situation. Then, a patient may be discharged, only to deteriorate as
delayed pulmonary edema ensues. A patient with significant exposure to toxic smoke should be
observed for 24-48 hours and undergo imaging tests, such as serial chest radiographs.
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.
After a severe burn, there is a hypermetabolic response that puts the patient at significant
nutritional risk. According to the American Burn Association (2014), if the patient fails to satisfy
the increased energy and protein requirements after a severe burn, it will result in multi-organ
dysfunction, increased susceptibility to infection, and increase the risk of mortality. An


40

immediate intervention is critical, as 20 percent of the bodys protein can be lost within the first
two weeks of a burn injury. Fluid imbalance, pain, and immobility make it difficult for a patient
with extensive burns to maintain his or her nutritional status, so they require optimal nutrition
therapy to support wound healing during the treatment and rehabilitation phases.
The soot from the fire may be affecting JA by settling on his vocal cords. Edema of the
larynx may occur, necessitating intubation to maintain an open airway and avoid inhalation of
soot into the lungs. Based on the physicians report, JA is in respiratory distress.
6) List all medications Mr. Angelo is receiving. Identify the action of each medication and any
drug-nutrient interactions that you should monitor.
JA is currently receiving 500 mg of ascorbic acid every 12 hours. Ascorbic acid is
important for the synthesis of bones and connective tissues, muscles, and blood vessels and it
also helps the body absorb iron. Ascorbic acid interacts with amphetamine.
Additionally, JA takes 15 mL of an oral solution of 0.12% chlorhexidine every 12 hours.
This is an antimicrobial used for cleansing skin and wound areas.
Another medication that JA takes is 20 mg of a famotidine tablet every 12 hours. This is a
histamine-2 blocker used to treat and prevent ulcers in the stomach and intestines. It interacts
with nicotine and renal dysfunction.
The patient receives 5,000 units of a heparin injection every 8 hours. This heparin
injection is an anticoagulant (blood thinner) that prevents the formation of blood clots. It should
not be used in those with uncontrolled bleeding, high blood pressure, or liver disease. Heparin
can interact with other anticoagulants such as warfarin, antihistamines, aspirin, and tetracycline
antibiotics.


41

JA also receives regular insulin injections every 6 hours to control blood sugar levels.
Insulin interacts with alcohol and may cause both hyperglycemia and hypoglycemia.
The patient takes a multivitamin tablet daily. A multivitamin is a combination of many
different vitamins that are normally found in foods, but are not taken in through the diet.
Multivitamins are also used to treat vitamin deficiencies caused by illness or pregnancy.
JA takes 220 mg of zinc sulfate daily in order to treat or prevent any post-burn zinc
deficiency.
Another tablet that JA takes is 5 mg of methadone every 8 hours. This is a narcotic drug
that reduces withdrawal symptoms in people addicted to heroin or other drugs without causing
the "high" associated with the drug addiction. Methadone interacts with alcohol and grapefruit or
grapefruit juice.
To further aid in pain management, JA is taking .5-1 mg intravenous injections every 3
hours of hydromorphone; an analgesic, antitussive narcotic. This medication interacts with
alcohol and may be habit forming.
The patient additionally takes 10 mg of oxandrolone every 12 hours. It is an anabolic
steroid that promotes the growth of muscle tissue, and is used to help regain weight lost after
surgery, severe trauma, or chronic infections. It interacts with warfarin.
JA also receives an 8.6 mg Senna tablet daily. This is a natural laxative and an aid to treat
constipation. It interacts with hydrocortisone.
JA drinks 100 mg of an oral liquid called docusate every 12 hours. This is a stool softener
that makes bowel movements softer and easier to pass. It is also used to treat or prevent

42

constipation, and to reduce pain or rectal damage caused by hard stools or by straining during
bowel movements. Docusate interacts with mineral oil and lactulose.
JA additionally uses a 1% topical cream of silver sulfadiazine daily, which is an
antibiotic that fights bacteria and yeast on the skin by treating or preventing serious infection on
areas with second- or third-degree burns. It interacts with sodium nitrite, hematologic toxicity,
hypersensitivity reactions, and porphyria.
JA is given 650 mg of acetaminophen every 4 hours as needed. Acetaminophen is a pain
reliever and a fever reducer used to treat many conditions such as headache, muscle aches,
arthritis, backache, toothaches, colds, and fevers. It interacts with alcohol. However, the patient
is allergic to acetaminophen.
The patient is given 100 mg of versed midazolam HCl in sodium chloride 0.9% 100 mL
IV infusion. Infusion is initiated at 1 mg/hour. This is a benzodiazepine used to sedate a person
who is having a minor surgery, dental work, or other medical procedure. It interacts with alcohol,
grapefruit or grapefruit juice, and obesity.
The patient is currently getting injected with 0.5-1 mg of hydromorphone (dilaudid)
intravenously every 15 minutes as needed. This is used to treat moderate to severe pain and
interacts with alcohol.
JA is also being injected intravenously every 15 minutes as needed with 50-100 mcg of a
fentanyl (sublimaze) injection. This is a narcotic used as part of anesthesia to help prevent pain
after surgery or other medical procedure. It also interacts with alcohol and grapefruit or
grapefruit juice.

43

JA receives a 10 mg/mL premix infusion of propofol (diprivan) starting at 25 mcg/kg/min
intravenously (continuous). Propofol slows the activity of the brain and nervous system. It is
used to promote relaxation before and during general anesthesia for surgery or other medical
procedures. It is used in critically ill patients who require a breathing tube connected to a
ventilator. Propofol interacts with alcohol.
The patient takes a couple of supplemental vitamins as well. He receives 100 mg of
thiamin, or vitamin B 3 times a day to aid in carbohydrate metabolism and 1 mg of folate 3 times
a day for cell growth and metabolism.
7) Using evidence-based guidelines, describe the potential benefits of early enteral nutrition in
burn patients.
In burn patients, nutritional status is linked to the stage of injury. Once admitted, many
factors such as patient history, pre-injury height and weight, and clinical appearance come into
play. Malnourished patients are at a greater risk for refeeding syndrome. Enteral supplements
maintain nutritional status and divert negative outcomes associated with malnutrition. Their
favorable cost and the fact that they are well tolerated are potential benefits of enteral nutrition.
They have wound healing and immune enhancing properties, including the amino acids
glutamine and arginine. Glutamine serves as a primary oxidative source for rapidly dividing
cells. Its supplementation has an effect on protein turnover and improves wound healing when
fed enterally. Glutamine benefits for burn patients also include reductions in infection rate,
length of stay, cost, and mortality. When it comes to arginine, its possible benefit in wound
healing is especially recognized in malnourished patients, or patients who are not metabolically
stressed.


44

Intragastric feeding in patients with severe burns should be instituted as soon as possible,
preferably before 18 hours, to prevent or minimize the onset of gastroparesis. Early enteral
nutrition support is an essential component of burn care to prevent illness, stress ulceration, and
the effects of hypermetabolism. The American Burn Association, the Canadian Clinical Practice
Guidelines, the Eastern Association for the Surgery of Trauma, and the American Burn
Association (ABA) state that enteral feedings should be initiated as soon as possible. One study
that examines this effect demonstrated that patients fed early had a shorter ICU length of stay
and reduced wound infection risk (Prelack, Dylewski, & Sheridan, 2006).
Very early enteral feeding (within the first 6-12 hours after injury) has many advantages
such as decreasing stress hormone levels, increasing immunoglobulin production, reducing stress
ulcers, as well as the risk of malnutrition and energy deficit (Rousseau, Losser, Ichai & Berger,
2013.) Initiating EN feeding within 24 hours of injury may also prevent infections (especially of
bacterial translocation), prevent Curlings ulcer, and reduce protein catabolism (Nelms, Sucher,
& Lacey, 2016).
8) What are the common criteria used to assess readiness for the initiation of enteral nutrition
in burn patients?
Before initiation of feedings, assessment should include a thorough evaluation of weight
loss and previous nutrient intake before admission, level of disease severity, comorbid
conditions, and functionality of the gastrointestinal (GI) tract.
Attaining access and initiating enteral nutrition should be considered as soon as fluid
resuscitation is completed and the patient is hemodynamically stable (Martindale et al., 2009). A

45

window of opportunity exists in the first 24 72 hours following admission or the onset of a
hypermetabolic insult.
9) What are the specialized nutrient recommendations for the enteral nutrition formula
administered to burn and trauma patients per ASPEN/SCCM guidelines.
Trauma, such as burns, lead to metabolic stress; the hypermetabolic, catabolic response to
acute injury or disease. ASPEN guidelines recommend 22-25 kcal/kg of actual body weight for
normal weight individuals. When the BMI is >30, the patient should receive approximately 2225 kcal/kg of ideal body weight.
As described in the 2009 ASPEN guidelines for nutrition support therapy in the adult
critically ill, traditional therapy was regarded as adjunctive care designed to provide exogenous
fuels to support the patient during the stress response. This support had three main objectives: to
preserve lean body mass, to maintain immune function, and to avert metabolic complications.
ASPEN guidelines document Grade B evidence that enteral nutrition should be started
early within the first 24-48 hours following admission. Also, ASPEN guidelines recommend
avoiding use of soy-based lipids for the first seven days of admission (Nelms, Sucher & Lacey
2016).
10) What additional micronutrients will need supplementation in burn therapy? What dosages
are recommended?
Additional micronutrients will need to be supplemented. These can include:
Vitamin A is recommended in a dosage of 5,000 IU per 1,000 calories provided via
enteral nutrition.
Vitamin C is recommended in wound healing, either 500 mg twice daily or 1-2 g/day.


In those who are zinc deficient, provide 15-25 mg of zinc per day.
46
Ensure that the daily recommended intake is met for Vitamin E, thiamin, riboflavin,
pantothenic acid, copper, manganese, and Vitamin K.
Electrolytes, including sodium, potassium, chloride, magnesium, and calcium, also need
to be monitored.
Although arginine and glutamine are not micronutrients, they are often given to aid in
wound healing in varying dosages.
Selenium is provided in dosages of 1,000 g/day parenterally for 14 days, then 200 g
twice daily PO (by mouth) or TF.
11) Using Mr. Angelos height and admit weight, calculate IBW, %IBW, BMI and BSA.
Height: 72 in. or 1.83 m.
Admit weight: 71.2 kg or 156.64 lbs.
IBW: 106 lb + (6 lb *12) = 178 lbs. or 80.9 kg
%IBW: 156.64 lbs / 178 lbs. = 88%
BMI: 71.2 kg / (1.83 m)2 = 21.26 kg/m2
BSA = square root of [(ht in cm * wt in kg) / 3600] = m2
= square root of [(183 cm * 71.2 kg) / 3600] = 1.90 m2
12) Energy requirements can be estimated using a variety of equations. The Xie and Zawacki
equations are frequently used. Estimate Mr. Angelos energy needs using these equations.
How many kcal/kg does he require based on these equations?

47

Ideally, JAs requirements would be estimated using indirect calorimetry, since he is on
ventilation. However, the Xie equation calls for 2,900 kcal/day and the Zawacki equation calls
for 2,736 (Xie et al., 2014). So, we recommend a total energy intake of 2,700-2,900 kcal/day.
Xie equation:
kcal/day = [1000 x body surface area] + [25 x burned surface area (% TBSA)]
= (1000 * 1.90 m2) + (25 * 40%) = 1900 + 10
= 2900 kcal/day (40.7 kcal/kg/day)
Zawacki equation: 1440 kcal/m^2/day
= 1440 kcal / 1.90 m2
= 2736 kcals/day, (38 kcals/kg/day)
13) Determine Mr. Angelos protein requirements. Provide the rationale for your estimate.
Typically burn patients require 1.5-2.0 g protein/kg body weight. Since JA experienced a
40% TBSA burn, we recommend around 2.0 g/kg, which equates to 142.4 g protein. This follows
closely with the recommendation from Xie, which estimates protein needs are 105-140 g protein.
Since the burns encompassed almost half of his body, we recommend 140 g of protein per day.
Protein needs calculations:
= 2 g/kg * 71.2 kg = 142.4g
Xie equation for protein needs:
= (0.15 * 2800) - (0.20* 2800) = 420 - 560 kcals / 4 kcal/g = 105-140 g
14) The MDs progress note indicates that the patient is experiencing acute kidney injury.
What is this? If the patients renal function continues to deteriorate and he needs continuous

48

renal replacement therapy, what changes will you make to your current nutritional regimen
and why?
Acute kidney injury (AKI) is a disorder where there is a sudden decline or cessation in
glomerular filtration rate (GFR) that leads to the failure to maintain electrolyte, fluid, and acidbase balance. AKI causes a person to produce a minimal amount of urine. The prognosis for AKI
is poor, and those with AKI can develop wasting, fluid and electrolyte disorders and azotemia
(buildup of nitrogenous waste products such as urea).
If the patients renal function continues to decline, he might need continuous renal
replacement therapy (CRRT). Protein should not be restricted during CRRT, so maintain current
recommended levels of protein intake. Monitoring electrolyte levels, especially potassium,
magnesium and phosphorus, will be important, so that supplementary electrolytes may be
administered when necessary. The energy recommendation during CRRT per day is 30-35
kcal/kg of body weight. In this case, his current nutritional regimen in terms of energy and the
amount of calories CRRT recommends are roughly the same: 2500 kcals/day. However, on
CRRT, the patient should only be getting 106.8 g protein per day (based on 1.5 g/kg/day) and
therefore should be switched to a formula meant for renal patients that contains more calories
and less protein, such as Nestles NOVASOURCE Renal.
Fluid intake should total 2,800 mL in the next 24 hours based on 1 mL/kcal. For effective
wound healing, a minimum of 30 mL/kg BW is recommended for patients over age 55, which
would total 2,136 mL per day. (Nelms, Sucher, & Lacey, 2016). Based on how extensive JAs
burns are, 1 mL/kcal would be appropriate and exceeds the minimum recommendation for

wound healing. Since JA will receive 1,800 mL from enteral nutrition, he should receive an
49
additional 1,000 mL from Lactated Ringers solution at a rate of 42 mL/hr.

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?
Propofol slows the activity in the brain and nervous system, allowing a patient to relax
before and during anesthesia. It is also used with critically ill patients that require a breathing
tube connected to a ventilator. Because propofol is lipid based, it therefore must be counted as a
source of energy. Propofol provides 1.1 kcal/mL and the patient is currently receiving 25 mL/hr,
which equates to an additional 660 kcal per day. In order to properly meet the patients energy
needs, these additional calories must be accounted for in his calorie recommendations. Tolerance
for this medication will be assessed by monitoring the patients heart, breathing, blood pressure,
oxygen levels, kidney functions, and other vital signs. The patient will also be monitored for
allergies to this medication as well as any rashes or pain surrounding the IV needle (Greenwood,
2009).
16) Identify at least 2 of the most pertinent nutrition problems and the corresponding
nutritional diagnoses.
JAs primary nutrition problems include that he is not meeting his increased energy and
protein needs from his burn and that he is receiving too much fluid, which is further affecting his
electrolyte balance and kidney function. These issues result in the nutrition diagnoses of
inadequate protein-energy intake, excessive fluid intake, altered nutrition-related lab values.
17) Write your PES statement for each nutrition problem.


50

Inadequate protein-energy intake R/T increased protein and energy needs due to severe
burn and altered kidney function AEB lab values indicating low serum protein and
albumin levels.
Excessive fluid intake R/T administration of excessive IV fluid in addition to enteral
feeding totaling 16.4 L of fluid in 24 hours AEB fluid intake of 230.7 mL/kg and output
of 23.8 mL/kg, indicating oliguria.
Altered nutrition-related lab values R/T catabolic response to injury, altered kidney
function, and metabolic acidosis AEB low blood pH, low serum bicarbonate,
hyperkalemia, hyperglycemia, hypocalcemia, hyperchloremia, hypomagnesemia, low
albumin, and very high levels of C-reactive protein.
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.
According to the nutrition prescription ordered by the physician, JA was meant to receive
20 mL/hr of Impact with Glutamine for the first 4 hours of hospitalization, then advance to 40
mL/hr for the next 4 hours, and finally advance to 60 mL/hr and remain at this rate. He was also
receiving Propofol at a rate of 25 mL/hr. According to this order, his energy intake would be
2,220 kcal in a 24-hour period.


= 1200 mL x 1.3 kcal/mL = 1,560 kcal
51

25 mL/hr x 24 hours = 600 mL x 1.1 kcal/mL = 660 kcal
= 1,560 + 660 = 2,220 kcal total
According to the Xie equation formulated for patients with severe burns, JA should be
receiving 2,900 kcal/day. To meet these needs through Impact with Glutamine (which is 1.3
kcal/mL), the patient will need to be given 93 mL/hour.
Xie: calories = [1000 x body surface area] + [25 x burned surface area (% TBSA)]
= (1000 * 1.90 m^2) + (25 * 40%) = 1900 + 1000
= 2,900 kcal/day
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 estimation of Mr. Angelos needs.
Based on the intake/output record, JA only received 1,395 kcal in the first 24 hours of
hospitalization, 735 kcal of which were from Impact with Glutamine and 660 kcal of which were
from Propofol. Based on the 735 kcal from enteral formula, JA received 44.1g of protein. This is
drastically less than the MDs diet order as well as his calculated needs for both energy and
protein. JA began receiving enteral nutrition early on in his hospitalization (in hours 8-16).
During hours 8-16, he received 228 mL of enteral formula, which was roughly 28.5 mL/hr. So it
is likely that he began receiving enteral formula during hour 8 or 9 if the feeding advanced
gradually, per the doctors order. However, the rate did not advance to 60 mL/hr in the following


52

8 hours (hours 16-24), as was ordered by the physician, because JA only received 42 mL/hr in
this 8-hour period (totaling 337 mL). Even if he received 40 mL/hr for the first 2 hours of this
timeframe and 60 mL/hr for the remaining 6 hours, his total intake would be more than is
indicated on the intake/output chart. So, it is clear that his diet orders were not followed closely.
Energy intake calculations:
565 mL intake x 1.3 kcal/mL
= 735 kcal from Impact with Glutamine
= 735 kcal + 660 kcal (from Propofol)
= 1,395 kcal total
Protein intake calculations:
= First day kcal (735 kcal from Impact Glutamine) x 0.24
= 176.4 kcal from protein / 4 kcal/g
= 44.1 g protein
20) One of the residents on the medical team asks you if he should stop the enteral feeding
because the patients blood pressure has been unstable. When recommendations can you
make to the patients critical care team regarding tube feeding and hemodynamic status?
Research indicated that receiving enteral nutrition early (within 48 hours) can decrease
mortality risk in patients with unstable blood pressure (Khalid, Doshi, & DiGiovine, 2010). I
would recommend continuing to provide enteral nutrition and possibly supplementing it with

parenteral nutrition, which is sometimes used to help stabilize the patients blood pressure
53
(Prelack, Dylewski, & Sheridan, 2006).

21) List factors that you would monitor to assess the tolerance to and adequacy of nutrition
support.
In both the inpatient and outpatient settings, nutrition support can be evaluated by looking
at lab values, such as blood glucose, blood urea nitrogen (BUN), electrolyte, creatinine,
magnesium, phosphorus, calcium, and triglyceride levels, as well as values that indicate liver
function and hydration status. In an inpatient setting, an overview of a patients fluid intake vs.
outputs as well as bowel sounds are also critical in assessing nutrition support, as they indicate
how well the digestive and urinary systems are functioning. In both settings, weight and vital
signs, like blood pressure, are also important, as they may indicate serious problems or risk
factors for disease.
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?
An indirect calorimetry test is the most accurate method for assessing energy needs in
inpatient settings. However, the test requires breathing into the equipment, so patients with
respiratory difficulties or low blood oxygenation, and those receiving mechanical ventilation
(like JA) are not good candidates for indirect calorimetry. In addition, cost and equipment
availability must be taken into account when ordering the test. When indirect calorimetry is not
available, ASPEN guidelines recommend patients with a BMI in normal range receive 25-30
kcal per kg of body weight and 1.2-1.5 g of protein per kg of body weight. However, JAs needs
are even higher because of tissue loss and the catabolic response associated with severe burns.


23) Write an ADIME note that provides your nutrition assessment and enteral feeding
54
recommendations and/or evaluation of the current enteral feeding orders.

Please refer to page XX for the ADIME note.

References
American Burn Association. (2014).
Drug Interactions. (2015). Retrieved from www.drugs.com/drug_interactions.php
Escott-Stump, S. (2015). Nutrition and Diagnosis-Related Care (Eighth ed.). Philadelphia, PA:
Wolters Kluwer.
Greenwood, J. (2009). ICU Guideline: Adjusting Goal Feed Rates in the Patient Receiving a
Propofol Transfusion. Retrieved from
www.criticalcarenutrition.com/docs/tools/Propofol.pdf
Impact Glutamine. (2015). Retrieved from
www.nestlehealthscience.us/products/impact%C2%AE-glutamine
Khalid, I., Doshi, P., & DiGiovine, B. (2010). Early Enteral Nutrition and Outcomes of
Critically Ill Patients Treated with Vasopressors and Mechanical Ventilation. Am J Crit
Care, 19, 261-268. Retrieved from www.medscape.com/viewarticle/723770


55

Martindale, R.G., McClave, S.A., Vanek, V.W., McCarthy, M., Roberts, P., Taylor, B., Cresci,
G. 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. Crit Care Med 37(5), 1-30. Retrieved from
www.learnicu.org/Docs/Guidelines/NutritionSupportAdult.pdf
Nelms, M., Sucher, K.P., & Lacey, K. (2016). Nutrition Therapy and Pathophysiology (3rd ed.).
Boston, MA: Cengage Learning.
Parkland Formula. (2015.) Retrieved from www.josephsunny.com/medsoft/parkland.html
Prelack, K., Dylewski, M., & Sheridan, R. (2006). Practical Guidelines for Nutritional
Management of Burn Injury and Recovery. Burns, 33, 14-24. doi:
10.1016/j.burns.2006.06.014
Pronsky, Z. M., & Crowe, J. P. (2012). Food Medication Interactions (17th ed.). Birchrunville,
PA: Food-Medication Interactions.
Rousseau, A., Losser, M., Ichai, C., & Berger, M. (2013). ESPEN Endorsed Recommendations:
Nutritional Therapy in Major Burns. Clinical Nutrition, 32, 497-502. doi:
10.1016/j.clnu.2013.02.012
Xi, P., Kaifa, W., Yong, Z., Hong, Y., Chao, W., Lijuan, S, Shiliang, W. (2014).
Establishment and Assessment of New Formulas for Energy Consumption Estimation in
Adult Burn Patients. PLOS ONE, 9(10). doi: 0.1371/journal.pone.0110409

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Running Head: CASE STUDY OF A BURN VICTIM

Case Study of a Burn Victim

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

Abdomen: Soft, non-tender. Bowel sounds normal. No masses, no organomegaly, partial

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

Docusate oral liquid (100 mg every 12 hrs.)

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

PTT: 26 sec (Within normal limits)

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

based on the intake/output report.

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

Energy requirements are measured by indirect calorimetry or estimated using standard

CASE STUDY OF A BURN VICTIM

traditional treatments (American Burn Association Medication, 2014).

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

Magnesium: 1.5 mg/dL

CASE STUDY OF A BURN VICTIM

Osmolality: 295 mmol/kg/H2O (Within Normal Limits)

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

additional 1,000 mL from Lactated Ringers solution at a rate of 42 mL/hr.

CASE STUDY OF A BURN VICTIM

CASE STUDY OF A BURN VICTIM

Propofol = 1.1 kcal/mL