NUT 116BL Name: Andre Smith

Major Case Study: Critical Illness & Nutrition Support

(11 questions; 60 points total)

Due 2/17/17 by 11 am
Submit Case Study online;
Turn in typed hard copy of ADIME note

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.

Initial admission information available from the medical chart:

Mr. G, a 32 yo industrial chemist, was severely burned over much of his trunk, arms, and
back in an accident at the chemical plant where he works. After emergency first aid at the
plant, he was transported by ambulance to the university hospital burn center. Mr. G was in
shock when he was admitted.

Physical exam: Pt experiencing severe pain, moderate respiratory distress. Unburned skin
is pale and cool. BP: 90/60; P 110 and weak; RR 22 and regular; Ht: 510; pre-injury wt:
165#

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 hospital course:

As soon as the shock was under control, Mr. Gs wounds were washed, debrided,
and dressed with silver sufadiazine using fine-mesh gauze. He was given a tetanus
shot and 600,000 units of procaine penicillin were administered q 12 hrs.
After 18 hrs, Mr. Gs UO was 40-50 ml/hr and bowel peristalsis had returned; patient
is responsive to pain, but limited alertness; breathing & respiration normal
By 24 hrs, a nasoduodenal tube was placed and position of the tip verified by
radiology to be past the ligament of Trietz.
On morning of second day (~ 30 hours), a Nutrition Consult was ordered for feeding
recommendation

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.

_____ 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.

__X_ 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.

2. Calculate Mr. Gs estimated energy needs on day 2 of hospitalization, using the

following methods. Show your work.
a. Quick shortcut per the ASPEN Critical Care Guidelines [25-35 kcal/kg BW] (2
pts)
Pre-Injury wt: 165#/2.2#/kg = 75 kg
25*75= 1875 kcal 35*75= 2625 -> 1875-2625 kcal

b. TEE using Mifflin St-Jeor formula with appropriate AF and IF (2 pts)

510= 70 inches*2.54cm/in = 177.8cm
(10*75kg)+(6.25*177.8cm)-(5*32)+5*1.1*1.5= 2817
(10*75kg)+(6.25*177.8cm)-(5*32)+5*1.*1*1.8= 3475

2817-3475 kcal/day

*MNT Pocket Guide 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 two ranges differ greatly. I would use the range generated from Mifflin St. Jeor
because it takes activity factor and the injury factor for the specific injury into
consideration. ASPEN is a general estimation for critically ill patients.
3. Calculate Mr. Gs estimated protein needs on day 2 of hospitalization. Show your work
and provide a goal range. (2 pts)
Burn --> 1.5 g/kg/d = 1.5*75=112.5
2.0 g/kg/d = 2*75= 150 --> 113-150 g protein/day
*MNT Pocket Guide pg 5

1. 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)

The formula should be able to provide a high amount of protein and calories as well
as micronutrients due to the impaired absorption that comes with critical illness.
The formula should also be able to balance fluid as fluid is lost through the wounds.

b. Give one example of an appropriate enteral formula meeting these

characteristics, using the UCDMC formulary provided on the course web site.
(2pt)

Osmolite 1.5 Cal is one example of an appropriate enteral formula. It provides a high
amount of calories and protein as well as electrolytes.

2. Mr. G is on IV Famotidine (Pepcid). What type of medication is this & why is it being
used? Why do you think this was used instead of the alternative Cimetodine liquid to
be put down the feeding tube? (Use the FMI text for this question) (2 pts)

Pepcid is an antiulcer, antiGERD, and antisecratory drug. The drug is used to reduce
the amount of acid secreted in the stomach. Cimetidine is not used because it is
known to precipitates tube feeding.

FDI pg 84, 140, 166-167

6. Describe 3 ways you could determine the adequacy of your recommendations for
energy and protein intake for this burn patient. (In other words, what will you monitor to
decide if your recommendations are adequate, and why?) (3 points)

1. Determine the protein status by monitoring biochemical values for prealbumin,

transferrin, and N balance.
2. Visually monitor wound healing and adjust protein accordingly.
3. The patient lost 5 kg, so monitoring further fluctuations in weight may be
essential for Mr. Gs care. Adjust energy requirements as needed.

*NUT 116BL Critical Illness slide 14

Ongoing Assessments
It is now day 10 post-injury and you have the following additional information available:
Some wounds are still open (new estimate: 15% TBSAB). More surgery for skin
grafting is scheduled in the next week.
Diet order during the past week has been changed by MD to: Jevity 1.2 @ 60 ml/hr,
plus PO intake as tolerated.
You have conducted kcal counts for the past 3 days. They show that pt is taking 100
kcals/day by oral intake, in addition to TF. Nursing I/Os indicate that the full TF
volume is being delivered each day.
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 needs using the current
information available.

a. Energy: (2 pt)
(10*70kg)+(6.25*177.8cm)-(5*32)+5*1.1*1.0= 1823.3
(10*70kg)+(6.25*177.8cm)-(5*32)+5*1.*1*1.5= 2734.9

1823-2735 kcal/d
*MNT Pocket Guide pg 3,5

b. Protein: (2 pt)
Post-Surgical Pt/Burn -> 1.5-2.0 g/kg/d = 1.5*70= 105
1.5-2.0 g/kg/d = 2.0*70= 140
105-140 g/protein/d
*MNT Pocket Guide pg 5

c. Fluid: (2 pt)
1 ml fluid/kcal = 1823-2735 ml fluid/d

*MNT Pocket Guide 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 -> 1.2 kcal/ml @ 60 ml/hr
1.2kcal/ml *60ml/hr = 72 kcal/hr -> 72kcal/hr*24 hr= 1728 kcal/day

b. Protein: (2 pt)
Jevity 1.2 -> 0.0555g/ml @ 60 ml/hr
0.0555g/ml *60ml/hr = 3.33g/hr -> 3.33g/hr*24 hr=79.9g/day -> 80g/day
 c. Fluid: (2 pt)
Jevity 1.2 -> 80.7% Water
60ml/hr*24hr/day=1440 ml/day
1440 ml*0.807 = 1162.08 ml water/day -> 1162 ml/day

9. You calculate Mr. Gs nitrogen balance at day 10, using the formula and values given
below.

N balance = g protein (UUN + 4) = 92 g pro (23 g + 4) = - 12.3 g N/d

6.25 6.25

Interpret the results of the nitrogen balance study above. Is the current TF order adequate
to meet estimated protein needs? (2 points)
The N balance calculated at day 10 is negative, which means that more nitrogen
is being excreted than taken in. A negative nitrogen balance is associated with
the acute response flow phase which is characterized by catabolism of skeletal
muscle. Mr. G could benefit from a higher protein intake from the tube feeding.

*NUT 116BL Critical Illness Slide 10

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

11. It is now 3 weeks since admission and Mr. G is now in a transitional care unit. Mr. Gs
wounds are closed and healing well. He is finally 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 a total of 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 total)

(4 pts) Recommended transitional feeding plan

To get ~1000 kcal/d from Jevity 1.2, the amount of fluid dispensed must be reduced
as the formula provides 1728 kcal/d when dispensed at 60 ml/hr. 34.8 ml/hr of Jevity
1.2 will provide ~1000kcal/d. Mr. G should also eat more food PO to supplement the
TF. He is recommended to consume 1823-2735 kcal/d, so he should consume at
least 823 kcal from food PO and gradually increase as tolerable. His food
preferences should be assessed so that he can consume more foods PO.
Alternatively, TF can be cycled at night and discontinued when the patient achieves
more than 50% kcal from PO.

1000 kcal/24 hr/ 1.2kcal = 34. 77ml/hr ->34.8 ml/hr

*NUT 116BL Enteral Nutrition Support slide 63

(2 pts) Monitoring plan

Assess pts ability to tolerate food PO and encourage more PO intake as pt

becomes more comfortable. Calorie counts should be done for the first few days to
ensure energy requirements are met. Pts weight can be monitored to ensure that
large fluctuations in weight are not occurring. If it appears that pt is not consuming
protein-rich foods, check lab values for albumin, prealbumin, and UUN to ensure
that pt does not go back to a catabolic state.

*NUT 116BL Enteral Nutrition Support slide 62

 Andre Smith
NUT 116BL Major Case Study 1 ADIME
2/17/17
A:
Pt hx: 32 yo male, industrial chemist experienced severe chemical burn on trunk, arms, and
back at chemical plant where he works.

MD Diet Order/Rx: Jevity 1.2 TF formula @ 60 ml/hr. PO intake as tolerated.

Anthropometrics: 70 kg, 70 in. Wt loss of 5kg over 10 days

BMI: 23.7 kg/m (day1) -> 22.1 kg/m2 (day 10)
2
IBW: 166# %IBW: 92.8%
(Normal BMI)

Nutrition Focused Physical Exam: Some open wounds still. 30% TBSAB( day 1) to 15%
TBSAB (day 10)

Labs: 2/17/17 albumin 2.7 g/dL (low), prealbumin 8 mg/dL (low), UUN 23 g/d (high)

Meds: IV Famotidine (Pepcid)

Estimated Needs: (Based on 70 kg)

Energy: 1823-2735kcal
Protein: 113-150g/d (1.5-2.0g/kg)
Fluid: 1823-2735 ml (1 ml/kcal)

Food and Nutrition hx: Pt c/o pain while eating PO with lowered appetite. Refuses PO
intake for now.

D:
1. Inadequate protein intake (NI- 5.7.1) r/t catabolic metabolic state d/t severe burn AEB
negative N balance calculation (-12.3 g N/d), low albumin (2.7 g/dL), low prealbumin (8
mg/dL), and high UUN (23 g/d).

I:
MNT Goal: Bring pt back to normal metabolic state and aid wound healing by providing
adequate protein as well as gradually encourage PO intake.

Recommendations: Increase protein provided by TF formula and possibly switch formulas

to provide adequate protein. The current diet order for 60 ml/hr of Jevity 1.2 only provides
80g/day.
Protein: Burn -> (1.5-2.0 g/kg/d) -> 105-140 g protein/d

Increase volume of Jevity 1.2 delivered by TF to at least 80 ml/hr. 80 ml/hr will provide
~107 g protein/d
If higher volumes of Jevity 1.2 are intolerable to the patient, a new formula, such as
Osmolite 1.5, may be considered.
Assess the pts pain tolerance daily and test if PO intake is tolerable

M/E
Monitor lab values weekly (albumin, prealbumin, UUN)
Ensure wounds are healing appropriately on a daily basis (check for reduction in
severity or infections)
Evaluate pts ability to intake food PO daily. Work with pt to adapting normal PO habits
again

ANDRE SMITH
UC Davis Clinical Nutrition, B.S. Candidate

February 17, 2017

Ht: 70 in * 2.54cm/in= 177.8 cm Wt: 165# * 1kg/2.2#= 75kg

IBW = 106 +(10*6)= 166# pg. 2
%IBW = (Current wt / IBW)*100 = 154/166 = 92.8% pg.2
Fluid: 1ml/kcal = 1823-2735 ml fluid/d pg. 6
BMI: kg/m2 -> 75kg/ 1.7782 m = 23.7 kg/m2 (day 1) pg. 1
BMI: kg/m2 -> 70 kg/ 1.7782 m = 22.1 kg/m2 (day 10) pg. 1
Protein Req: Burn -> (1.5-2.0 g/kg/d) -> 105-140 g protein/day pg. 5
Energy: (10*70kg)+(6.25*177.8cm)-(5*32)+5*1.1*1.0= 1823.3
(10*70kg)+(6.25*177.8cm)-(5*32)+5*1.*1*1.5= 2734.9 pg. 3, 5
MNT Pocket Guide pg.2-6________________________________________________
New Jevity 1.2 Rx:
0.0555g/ml *80ml/hr = 4.44 g/hr -> 4.44g/hr*24hr= 106.56 g/day