Metabolic Stress

Worked with Kaylee Jacobs

Assessment

65 year old male; ht: 72; wt: 71.2kg; BMI: 21.3; admitted to surgical intensive care unit for level 2
trauma and treatment of serious burns (mostly 2nd degree) covering 40% of his body (40% TBSA burn) as
well as suspected smoke inhalation injury during trailer fire; respiratory failure; acute pain due to injury;
malnutrition; on mechanical ventilator; patient started on fluid resuscitation per Parkland formula using
lactated Ringers @610mL/hr for first 8 hours and decrease to 305mL/hr X 16 hours; meds noted; labs
noted; current enteral nutrition support order: Impact with glutamine @ 20mL/hr, advance 20mL/hr
every 4 hours to 60mL/hr

Comparative data-

Recommended daily calorie intake: 2,400-2,600kcals

Recommended daily protein intake: 140-145g

Recommended daily fluid intake: 2,400-2,600 fl oz

Diagnosis

Inadequate protein-calorie intake R/T inaccurate enteral nutrition formula AEB current enteral nutrition
order and lab values

Intervention

RD prescribed continuation of fluid resuscitation and alteration in enteral nutrition support formula. RD
prescribed Impact 1.3 with Glutamine @80mL/hr which provides 2,500 calories, 150 grams of protein,
and 807 fl oz of free water. Water flushes of 310 fl oz 3 times per day. Start at 10-20cc/hr within first 24-
48 hours, advance to goal rate within 72 hours.

No education was provided at this time.

Monitoring and Evaluation

RD will visit patient daily to monitor tolerance of enteral nutrition formula and assess patient weight and
lab values via charts and observation.
1. 1st degree: epidermis, 2nd degree: dermis, 3rd degree: subcutaneous tissue, 4th degree: muscle
Mr. Angelo has mostly 2nd degree burns, 40% TBSA burns
2. The percentage of burn, helps guide treatment decisions including fluid resuscitation. You can
estimate the body surface area on an adult that has been burned using multiples of 9.
3. The goal of fluid resuscitation is to maintain adequate tissue perfusion but also avoiding excessive or
deficient fluid administration. The Parkland formula is the total fluid requirement in 24 hours. LR
(lactated ringers) is a common IVF used in burn patients, which is composed of sodium chloride,
potassium chloride, sodium lactate, and calcium
4. Smoke inhalation that causes injury through several mechanisms- thermal injury to the upper
airway, irritation or chemical injury to the airways from soot, asphyxiation, and toxicity from carbon
monoxide and other gases. These effects can cause infection, pneumonia, and possible mortality
5. Burns greatly increase energy expenditure and therefore increase patient nutrient needs by up to
100%
6. See labs
7. Early enteral nutrition in burn patients helps to avoid accelerated breakdown of muscles
8. Whether they hemodynamically stable and if they have a functioning gut, but are not able to eat
sufficient calories orally
9. Ireton-Jones equation for increased energy needs in patients experiencing trauma or burns (see
chart note)
10. Zinc 220mg, Vitamin A 5000 IU per 1000kcal, Vitamin C 500mg 2X/day (glutamine and Omega-3)
11. IBW: 83kg, %IBW: 86%, BMI: 21.3, BSA is 40% burns
12. See chart note
13. See chart note. Recommendations are elevated due to increased needs and avoidance of
accelerated breakdown of muscles in burn victims
14. This means that his renal function is deteriorating, and he may eventually need parenteral nutrition
supplementation because his GI is not functioning properly
15. Propofol provides 1.1kacls/mL as fat, therefore, administration of propofol also provides calories
from lipid and needs to be included in calculation of total calorie intake to avoid overfeeding. Due to
this, I should lower the calories administered by the enteral nutrition feeding in order to account for
the extra calories provided by propofol. I will assess his tolerance to this medication by looking for
common symptoms such as nausea, cough, burning around IV needle, itchy skin/rashes, numbness
or tingling, confusion, muscle pain, etc.
16. Inadequate protein-calorie intake and malnutrition
17. Inadequate protein-calorie intake R/T inaccurate enteral nutrition formula AEB current enteral
nutrition order and lab values
Malnutrition R/T inaccurate enteral nutrition formula AEB current enteral nutrition order and lab
values
18. See chart note
19. See chart note, energy and protein provided is not meeting estimation of Mr. Angelos needs
because it is being administered at 20cc/hr and should be administered at 80cc/hr
20. Continue to monitor the patients enteral feedings because he requires food to heal and cannot
consume food orally. If necessary TPN feedings may need to be considered
21. I would monitor lab values, weight, bowel movements and GI function
22. Ireton-Jones equation because it takes into account the burns and trauma that require increased
energy for healing and preventing accelerated breakdown of muscles. It is important to take into
consideration the alertness of the patient, ability to self-feed, GI function, and metabolic stress. CRP
protein is a good test to identify stress level of the body.