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The following is an overview of pertinent biochemical, clinical, and anthropometric information needed to assess the nutritional status of the burned patient upon admission. An assessment of the patient's increased nutritional needs (kcal, protein, vitamins, and minerals) as a result of burn trauma and the most appropriate mode of delivery of nutritional support is outlined. Follow-up and course of treatment, including routine collection of pertinent data and implementation of nutritional support, with special attention to route of delivery, in response to the progressive status of the patient is included.
Admit date: 8-25-95
Patient: 31 years of age, white male
Diagnosis: 90% second and third degree partial and full thickness thermal burns (burns to extremities, scalp, face, thorax and back) - intubated; tibula/fibula fracture left leg; crushed right ankle; possible inhalation burns; ileus
Medical History prior to fire: Not available
Medications: Analgesics, Senekot, Vitamin C, Multi-Vitamin/Mineral Supplement , Valium
| Pertinent Lab Data | ||
|---|---|---|
| Na : 141 mmol/L | Glu: 122 mg/dL | Ca : 9.5 mg/dL |
| K : 4.0 mmol/L | BUN: 22 mg/dL | PO4: 3.6 mg/dL |
| Cl : 105 mmol/dL | Cr : 0.9 mg/dL | Mg : 1.9 meq/L |
Height: 180 cm
Body Weight: Admit weight (dry weight): 86 kg (The "dry" body weight measured immediately after admit should be used for the calculation of nutritional needs WHEN information on the patient's normal weight is not available. This admit weight will more accurately reflect nutritional status than the "wet weight" obtained during fluid resuscitation. Note that he original weight recorded for this burn patient, 100 kg, reflects "wet" weight).
Desirable Body Weight: approx. 85 kg
Current Diet Order/Nutrition Support: Nothing by mouth (indicated as 'NPO')
Estimated Calorie/Protein Requirements: 3850 kcal/day (two times the estimated basal energy expenditure (BEE)); 125-130 gm protein (150 non-protein kcal/gm nitrogen)
Immediate Assessment of Nutritional Status:
- Patient within normal weight range upon admit; general nutritional status cannot be determined due to lack of prior medical information and difficulty in interpreting laboratory data since results are effected by the current medical condition of the patient
- Gastrointestinal feeding (feeding via the gastrointestinal tract-either by providing foods or tube feedings) is not an option at this time due to ileus, impaired respiration, and trauma to head and neck
- Nutrition care level is considered comprehensive due to extreme increase in metabolic needs
Goals of Nutrition Therapy: Provide optimum nutrition compatible with 1) increased energy expenditure and nutrient needs and 2) current medical condition.
Proper provision of nutrients for this critically ill patient will:
- Minimize loss of lean body mass
- Prevent weight loss in excess of 10% of pre-injury weight
- Promote wound healing and aid in the prevention of infection
Plan:
To evaluate success in achieving nutritional goals and to modify goals in response to changes in the patient's medical and nutritional status:
- Monitor daily calorie/protein intake records
- Monitor weight changes twice weekly
- Monitor changes in pertinent lab values
- Monitor progress of wound healing
Nutritional recommendations: Upon resusitation (replacement of fluids and electrolytes which may take 3-4 days), recommend initiation of total parenteral nutrition (TPN) starting at @ 125 cc/hr (the maximum infusion rate that is typically tolerated by an adult burn patient on the 4th day post-burn, see ref.#1 below), using the following formula:
- 55 g/L amino acid
- 150 g/L dextrose
- 200 cc 20% lipid
Administration of this TPN formula would provide 2640 kcal and 165 gm protein in 3 liters of fluid, over a 24 hr period. This quantity of TPN solution will not meet all of the patient's calculated kcal needs. If the patient tolerates this volume, then the TPN volume should be increased over the next few days. (NOTE: Sometimes it is not possible to meet the high kcal needs with TPN due to hyperglycemia and excess fluid load. If this is the case, then it is best to at least meet protein needs and get as close to the kcal needs as can be provided without supplying excess carbohydrates.)
Reference:
1. Chiareli, A. amd Siliprand, L. Burns. IN: Nutrition in Critical Care. Mosby: St. Louis; 1994, p. 591.
Continue on with discussion of Patient Progress and Nutritional Support
Return to Case 5: Burn Patient Home Page
- Kathy Talcott, graduate student and
- Deborah E. Kipp, Ph.D., R.D., Associate Professor
- Dept. of Dietetics and Nutrition, KUMC
1/23/96