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You are the RD in the burn unit of your hospital. You have been consulted for a nutrition
assessment of Mr. G, and you will be responsible for follow-up assessments, planning,
and monitoring throughout his hospitalization.
Laboratory: The following tests were ordered: CBC, blood type and cross-match, Chem
20 screening panel, ABGs, and UA.
Impression: 30% TBSA, partial and full-thickness burns over lower part of face, neck,
upper back, arms, hands, and upper thighs.
Plan: IV therapy was initiated with Ringers lactate. A Foley catheter was inserted.
Urinary output, P, and BP monitored hourly. NPO x 12 hrs or until hemodynamic stability
achieved. NG tube placed for stomach decompression. Maalox q 2 hrs through NG
tube.
Initial Assessment
Using the above information, assess the patients nutritional needs at the time of the
initial consult, on day 2 of admission.
1. Which of the following statements best describes your nutrition screening of Mr. Gs
risk level? (1 pt)
_____ Minimal risk (patient is at or above IBW, no weight loss prior to admission); no
specialized nutrition therapy over the first week of hospitalization is required.
_____ Moderate risk (patient is at or above IBW, no weight loss prior to admission);
limited alertness duration likely > 72 hours; trophic feeds recommended to be started
within 48 hours of admission and continued through first week of hospitalization.
__X__ High risk (patient is at or above IBW, no weight loss prior to admission) with
high injury severity; enteral feeds recommended to be started within 48 hours of
admission; enteral nutrition support recommended to provide >80% of goal energy &
protein needs.
_____ High risk (patient is at or above IBW, no weight loss prior to admission) with
high injury severity; trophic feeds recommended to be started within 48 hours of
admission; parenteral nutrition support recommended to provide >80% of goal
energy & protein needs.
PR pg 1, 3
b. TEE using Mifflin St-Jeor formula with appropriate AF and IF (2 pts)
(10 x 75 kg) + (6.25 x 177.8 cm) - (5 x 32) + 5
750 + 1111.25 - 160 + 5
1706.25 kcal
PR pg 3, 5
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)
The range obtained from the ASPEN Critical Care Guidelines (1875-2626 kcal) method
was much lower than the range obtained from the Mifflin St-Jeor formula (2815-3472
kcal). In fact there is almost a difference of a 1000 kcal. I would choose the Mifflin St-
Jeor since the values are higher and Mr. G is a burn patient and will therefore have
more energy requirements so that he can heal and rebuild his body. Another important
note is that the Mifflin St-Jeor equation takes into account that he is confined to bed
(AF) and has 30% TBSAB (IF).
PR pg 3, 5
3. Calculate Mr. Gs estimated protein needs on day 2 of hospitalization. Show your
work and provide a goal range. (2 pts)
~112.5-150 g Pro/d
PR pg 5
4. Based on the patients needs, consider the enteral formula to recommend
a. Describe two desirable features or characteristics of the type of formula
you would select and recommend. (refer to the UCD TF lecture) (2 pt)
1) First of all the formula needs to be higher in calories so that the patient can
compensate for his higher energy needs since 30% of his body is burned.
2) Also, the pt will need a formula that is higher in protein so he can have what he needs
to begin the healing process and also to make for what he lost from the burns.
7. Re-assess Mr. Gs estimated energy, protein, and fluid needs using the current
information available.
a. Energy: (2 pt)
(10 x 70 kg) + (6.25 x 177.8 cm) - (5 x 32) + 5
700 + 1111.25 - 160 + 5
1656.25
1656.25 x 1.1 x 1.0 = 1821.875
1656.25 x 1.1 x 1.5 = 2732.8125
~1822-2733 kcal
PR pg 3,5
b. Protein: (2 pt)
105-140 g Pro/d
PR pg 5
c. Fluid: (2 pt)
PR pg 6
8. Calculate the energy, protein, and fluid provided by the current TF regimen. Show
your work
a. Energy: (2 pt)
Jevity 1.2 60 mL/hr
9. You calculate Mr. Gs nitrogen balance at day 10, using the formula and values given
below.
Interpret the results of the nitrogen balance study above. Is the current TF order
adequate to meet estimated protein needs? (2 points)
A negative nitrogen balance means that Mr.G is excreting more nitrogen than he is
taking in. This indicates that he could be in a catabolic state and is not getting enough
protein to meet his needs. This can be confirmed by the fact that the Jevity 1.2 formula
gives him about 80g of protein a day which does not even meet the absolute minimum
of a 105g of protein that he needs.
NTP pg 57
10. Write an ADIME note for your day 10 follow-up assessment of Mr. G. (22 points)
Hints: Follow the ADIME note guidelines provided on the course web site. Use
subheadings. Be sure to evaluate his current anthropometrics (and any trends seen),
current kcal/pro needs, adequacy of the current diet order (including both the TF and
PO intake), and current labs. What do the anthropometric and biochemical data reveal?
Is the current diet order adequate and realistic for the patient? Write a PES statement
that reflects your assessment and include it in your note. In the Plan section, make very
specific nutrition support and monitoring recommendations for this patient at this point in
time.
.
*REMEMBER to turn in hard copy of your typed ADIME note & attach a calculations
sheet to your note; remainder of the assignment is to be submitted online
Assessment
Pt Hx: 32 yo M admitted to burn center for severe burns 30% TBSAB, s/p 15% TBSAB
after 10 days
MD Diet Order/Rx: Jevity 1.2 @ 60 mL/hr (1728 kcal, 80 g Pro, 1162 mL) & PO intake
as tolerated
Anthropometrics: 5 10, UBW 75 kg, CBW 70kg, IBW 75.5 kg, IBW% 99%, 6.7% wt
loss (severe), BMI 22 nl
Overall Appearance: Some wounds still open ~15% TBSAB
GI: Has peristalsis
Cognition: Awake and talking
Skin: Some wounds still open 15% TBSAB noted, no significant edema
Biomedical Lab Data: UUN 23g/24 hr
Medication: IV Famotidine (Pepcid), Maalox q 2hrs, Ringers lactate
Estimated Nutrient Needs (based on 70 kg wt)
Energy: ~1822-2733 kcal
Protein: 105-140 g Pro/d
Fluid: 1822-2733 mL fluid min per day
Food and Nutrition Assessment: refuses to eat b/c poor appetite & difficulty eating d/t
pain
PR pg 1-3, 5, 6
NUT 116Bl Enteral Support Slides 21-24, 59
Diagnosis
Inadequate protein intake (NI-5.7.1) r/t lower protein content of Jevity 1.2 Cal AEB by N
balance value of -12.3 g N/d.
Inadequate energy intake (NI-1.2) r/t insufficient diet order of Jevity 1.2 Cal AEB by
6.7% (severe) wt loss.
Intervention
1) To increase energy and protein intake through TF w/i ranges of 1822-2733 kcal and
105-140 g Pro/d to promote recovery
2) Specific Recommendations
New Diet Rx: TwoCal HN initiate 20 mL/hr, advance 20 mL/hr p 4-6 hours or as tol
and then advance 15 mL/hr to reach goal rate of 55 mL/hr (2640 kcal, 110 g Pro/d,
924 mL fluid)
Recommend 240 mL water flush Q6 hours (=960 mL/d) to give total of 1884 mL fluid/
d
PO intake as tol
Monitoring/Evaluation
1) order pt UUN values to monitor nitrogen balance to ensure pt is receiving adequate
protein
2) monitor wt to see if pts nutritional needs are being met (if wt loss then may need to
change TF regimen)
3) Monitor I/O to determine how much of diet order is being delivered to pt
4) see if any PO intake or whether will try PO as tol
24 hr x 60 mL/hr = 1440 mL
0.807 x 1440 mL = 1162.08 mL fluid ~ 1162 mL fluid
Anthropometrics
a) Energy
~1822-2733 kcal
PR pg 3,5
b) Protein
105-140 g Pro/d
PR pg 5
c) Fluid
1822 kcal x 1 mL fluid/kcal = 1822 mL
2733 kcal x 1 mL fluid/kcal = 2733 mL
PR pg 6
New Diet Rx
a) Energy
b) Protein
55 mL/hr x 24 hr x 1L/1000mL x 83.5 g Pro = 110.22 ~ 110 g Pro/d
c) Fluid