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Documente Cultură
116BL
Winter
2016
1. Calculate
Mr.
Gs
estimated
energy
needs
on
day
2
of
hospitalization,
using
the
following
methods.
Show
your
work.
a.
Quick
shortcut
as
used
by
UCDMC
burn
unit
[35-40
kcal/kg
BW]
(2
pts)
165#/ (2.2 #/kg) = 75 kg
75kg/ (35-40 kcal/ kg) = 2,625 3,000 kcal
PRG
b. TEE
using
Mifflin
St-Jeor
formula
with
appropriate
AF
and
IF
(2
pts)
75kg, 32 yo
510 = 70 x (2.54 cm/in) = 177.8 = 1.78m
MSJ - (10 x 75kg) + (6.25 x 177.8) (5 x 32) + 5 x (IF 1.5-1.85) x (AF 1.1)
= (750 + 1,111.25 160 + 5) x (IF 1.5-1.85) x (AF 1.1)
= 2,815- 3472 kcal
PRG
c. Comment
on
whether
these
two
estimates
differ
or
are
similar,
and
what
you
would
use
as
your
actual
energy
recommendation
for
this
patient.
Provide
justification
for
why
you
selected
this
energy
recommendation.
(2
pts)
Both methods are within the same ranges, but to estimate energy needs the MSJ equation would
be best to use as it takes into account the injury factor and activity factor. A higher IF and AF
will result in a higher kcal need, whereas the UCDMC uses an estimation of kcals/kg without
taking into account individual factors that can increase needs.
2. Calculate
Mr.
Gs
estimated
protein
needs
on
day
2
of
hospitalization.
Show
your
work.
(2
pts)
1.5 2.0 g PRO/ kg BW
1.5 2.0 x 75kg = 112.5-150 g PRO
PRG
3.
Discuss
the
effects
of
trauma
on
macronutrient
metabolism.
(3
points.)
Trauma
causes
a
hyper
metabolic
state
causing
accelerated
energy
expenditure,
which
turns
the
body
from
storing
macronutrients
to
breaking
them
down
for
energy
utilization.
Proteins
are
catabolized,
lipids
are
oxidized,
and
the
body
is
altered
for
carbohydrate
catabolism.
After
a
trauma
cytokines,
ACTH,
and
Catecholamine
are
secreted
that
act
on
the
body
to
repair
tissue
and
stimulate
use
of
macronutrients
for
repair
and
energy
Lecture
Notes
The
patient
tells
you
it
is
difficult
for
him
to
eat
by
mouth
due
to
pain,
and
that
he
doesnt
have
much
of
an
appetite,
he
refuses
to
try
eating
for
now.
Current
BW:
70
kg,
no
significant
edema
Current
labs:
albumin
2.7
g/dL,
prealbumin
8
mg/dL,
UUN
23
g/24
hr
7.
Re-assess
Mr.
Gs
estimated
energy,
protein,
and
fluid
need
using
the
current
information
available.
a. Energy:
(1
pt)
Formula
Sheet
MSJ - (10 x 70kg) + (6.25 x 177.8) (5 x 32) + 5 x (IF 1.0-1.5) x (AF 1.1)
= 700 + 1,111.25 160 + 5
= 1,656.25 x (IF 1.0-1.5) x (AF 1.1)
= 1,822 2,733 kcal
b. Protein:
(1
pt)-
Formula
Sheet
70 kg x 1.5-2.0 g PRO/ kg BW = 105- 140 g PRO
c. Fluid:
(1
pt)-
Formula
Sheet
1 mL/ kcal
1822- 2733 kcal / (1mL/kcal) = 1822- 2733 mL
8.
Calculate
the
energy,
protein,
and
fluid
provided
by
the
current
TF
regimen.
Show
your
work
a. Energy:
(1
pt)
Formula
Sheet
Jevity 1.5 @ 60mL/hr 1.5 kcal/mL
60mL/hr x 24 hr = 1,440 mL/ day x 1.5 kcal/mL
= 2,160 kcal
b. Protein:
(1
pt)-
Formula
Sheet
Jevity 1.5 @ 60mL/hr 64g PRO
64g PRO/ 1000mL = x g PRO/ 1,440mL TF
= 92 g PRO
c. Fluid:
(1
pt)-
Formula
Sheet
Jevity 1.5 @ 60mL/hr 76% H2O
1,440 kcal x 0.76 H2O = 1,094 mL H2O
MD
Diet
Order
Jevetiy
1.5
@
60mL/hr
x
24
hours
PO
intake
as
tolerated
Anthropometrics
Ht.
1.78m
UBW
75
kg
CBW
70kg
Severe
weight
loss
of
7%
in
10
days.
IBW
75kg
(93%)
BMI
22.1,
normal
Labs
10
day-
post
surgery
Pre-albumin
8
mg/dL,
low
UUN
23
g/24
hr
Nitrogen
balance:
-12.3,
high
nitrogen
output,
low
protein
intake
Medications
Famotidine(Pepcid):
Histamine H2 Receptor Antagonist.
Anti-ulcer, anti -ERD, anti-secretory
Energy
Requirements
based
on
70kg
BW
Kcal
MSJ:
1,822 2,733 kcal
IF
1.0-1.5
(Burns
0-20%
TBSA);
AF
1.1
Protein
105-140
g
(1.5-2.00
g/kg
BW
Fluids
1,822- 2,733 mL
Food
&
Nutrition
Hx
Jevity
1.5
@
60mL/
hr.
Kcal
MSJ
2,160
kcal
(1.5kcal/mL)-
meets
kcal
requirement
Protein
92
g
(64g/1000mL)-
inadequate,
proving
87%
needs
Fluids
1,094
mL
(76%
H2O)-
inadequate,
administer
flushes
D:
PES
Statements
1. Inadequate
protein-
energy
intake
(NI-5.3)
r/t
inadequate
TF
regime
of
Jevity
1.5
formula
AEB
meeting
87%
protein
from
REE
and
negative
nitrogen
balance.
2. Increased
nutrient
needs
(NI-5.1)
r/t
hyper-catabolism
from
burns
15%
TBSA
AEB
requiring
at
most
2,700
kcal
from
REE
and
1.0-1.5
g
PRO/
kg
per
day.
I:
MNT Goal: Promote pt. wound healing and minimize catabolic loss by providing nutritional
support, adequate intake of vitamins, minerals, kcals and protein, and meet fluid
recommendations.
Recommendations
a) Diet Rx: Pt. may benefit from a more concentrated high protein tube feed formula.
Promote daytime PO with gradual increase of tolerable foods
Jevity
1.5
Modification
@
80mL/hr
TF
kcal
2,000kcal
TF
protein
115
g
TF
fluids
1,368
mL,
250mL
@
4
times
a
day
Goal
Regimen
Jevity
1.5
@
75mLhr
x
24
hr
(=
1,800
mL,
2,700
kcal,
155
g
protein,
1,368
mL
free
water)
+
250
mL
flushes
QID
b) Specific recd: Pt. will benefit from a high-energy dense formula meeting REE to
alleviate increase in energy expenditure due to hyper catabolic state.
PT will benefit from an increase in protein intake to meet REE by consuming a
complete protein formula to help restore damaged tissues and improve nitrogen balance.
c) Diet instructions given to patient of increase protein in diet, and increase kcal
concentration in formula and adequate fluid intake. Handout given to pt. that describes
in detail pt.s formula and mapped out administration of feeding and necessary flushes.
Any questions regarding medication to be addressed to MD, and TF questions addressed
to RD.
Compliance to gradual PO intake may be difficult as pt. experiences body pain, decrease
appetite, and it will be difficult to experience oral intake. Pt. will comply to new TF regimen as
it will be administer to
M/E
Monitor daily calorie counts, wound healing, tolerance to nutrition support, weight,
biochemical lab values, fluid intake and output.
Follow up with pt. 1-2 days to acquire feedback on personal well being with new administered
formula, to make sure pt. is not having further complications and meeting energy requirements
from REE.
Clincial
Nutrition
Student
2/11/2016
13.
It
is
now
3
weeks
since
admission
and
he
is
now
in
a
transitional
care
unit.
Mr.
Gs
wounds
are
closed
and
healing
well.
He
is
interested
in
trying
to
eat
more
foods
orally
and
his
appetite
is
returning.
How
could
his
current
continuous
TF
regimen
(the
one
recommended
in
your
note
above)
be
modified
to
provide
approximately
1000
kcal/day
and
not
interfere
with
his
intake
at
meal
times?
Make
recommendations
for
an
appropriate
transitional
TF
plan/order
and
how
to
monitor.
Make
a
specific
recommendation
for
both
the
TF
plan
and
monitoring.
(6
points)
His current TF regimen needs to decrease in rate to administer the 1,000 kcal needed and
cycle TF at night so it does not interfere with his intake at meal times. Recommendation for
transitional feeds from TF to PO will be to adjust TF regimen based on pt.s oral intake and
intake of oral supplement and snacks monitored by accessing a diet analysis of caloric intake
and food waste and pt.s contentment with PO. Also, consider cycled TF at night and monitor
by checking the rate TF is administered.
TF regimen to be modified at 60mL/hr x 12 hours at night to provide 1,080-kcal/ day.
Calculations
in
ADIME
note
IBW
%
=
70kg/75
kg
x
100
=
93%
&
Weight
loss:
75kg
70
kg/
75
kg
x
100
=
7%
BMI:
kg/
m2
=
70kg/
(1.78)2
=
22.1
Formula:
Jevity
1.5
@
75mL/hr
Kcal=
75
mL/hr
x
24hr
=
1,800
mL
x
1.5
kcal/mL
=
2,700kcal
Protein:
64g/1,000mL
=
x
g
PRO/
1,800
mL
TF
=
115
g
PRO
Fluids:
1,800mL
x
76%
H2O
=
1,368
mL
2,278
mL
1,368
mL
=
910
mL
~
1,000mL
250mL
flushes
QID