Describe how burn wounds are classified. Identify and describe Mr. Angelo’s burn injuries.
Burn wounds are classified using four degrees that are based on the severity of how many layers of the dermis have been damaged; the higher the degree of burn classification, the more severe the burn injury and damage done to the patients skin and body. In the case of Mr. Angelo’s burn injuries, he sustains both 2nd and 1st degree burns covering approximately 40 percent of his body.
Explain the “rule of nines” used in assessment of burn injury.
When assessing burn injuries, the “rule of nines” is a formula to assess how much body surface area (BSA) has been damaged. The “rule of nines” is only used in the case of more severe burn injuries that include anything over 2nd degree burns sustained. Nine points on the body are examined in indicating the severity of the burns, which include- the head, the anterior torso, the upper back, arms, anterior abdomen, lower back, perineum, anterior leg, and posterior leg.
The primary goal of fluid resuscitation is to ensure that just the right amount of hydration is present in treatment of the burn patient in order for proper tissue perfusion to occur. Too much or too little are both harmful in the case of burn injuries, which is why a very specific formula is used to select appropriate amount of fluid resuscitation. The Parkland formula is used in these cases; the adult dosage would be 2-4ml LR x kg body weight x % TBSA burn. Most commonly glucose and water, perhaps also plasma is used in fluid resuscitation in the first 24 hours, after which colloids may be introduced. The components of the solution include plasma and glucose as the first preference, after which comes isotonic crystalloids, hypertonic solutions, and colloids.
What is inhalation injury? How can it affect patient management?
Inhalation injury has to do with the smoke inhalation that damages the internal respiratory areas of the patient as a result of excessive carbon monoxide, soot, and other debris that is breathed in during the trauma, which can be extremely damaging and dangerous to burn victims. It can affect patient management dramatically by needing to address these complications as urgently as any of the physical burns forcing intubation in order to save the patient from death as a result of the poisonous fumes that have been inhaled in the smoke.
Burns are often described as one of the most metabolically stressful injuries. Discuss the effects of a burn on metabolism and how this will affect nutritional requirements.
Burn injuries are one of the most metabolically stressful injuries due to the long lasting and detrimental effects it can have on the individual. Many problems arise in the burn victim which include hypermetabolic response, dysfunction in multi-organ systems, muscle protein degradation, insulin resistance, and other disruptions to the body’s functions that will change metabolism. Due to these changes, nutritional requirements, which may include a high carbohydrate and high protein diet that is often delivered through tube feeding may be necessary for the patients healing process to occur adequately.
6.List all medications that Mr. Angelo is receiving. Identify the action of each medication and any drug–nutrient interactions that you should monitor.
Ascorbic Acid 500mg every 12 hrs- helps to alleviate some pain and also keep urinary output levels at a healthy range to avoid possible renal ischemia
Chlorhexidine 0.12% oral solution 15 mL every 12 hrs- treatment of inflammation
Famotidine 20 mg every 12 hrs- treatment of upper gastrointestinal problems such as ulceration and bleeding
Heparin injections 5000 units every 8 hrs- treatment to avoid blood clots
Insulin shot every 6 hrs- treatment of metabolic issues involving insulin resistance and hyperglycemia
Multi-vitamin daily- assistance of adequate macro and micro nutrients that is needed for healing
Zinc Sulfate 200mg daily- ensure sufficient levels of zinc are present to help in healing the burns.
Methadone 5mg every 8 hrs- relief of neuropathic pain caused by burns
Oxandrolone 10mg every 12 hrs- synthetic derivative of testosterone to help increase LBM to assist in healing
Senna 8.6 mg daily- used as a laxative but must be cautious of excessive fluid loss
Docusate oral liquid100mg every 12 hours- stool softner
Silver Sulfadiazine 1% topical cream daily- treatment of actual burn wounds to help in pain and healing
Acetaminophen 650my every 4hrs. as needed- aids in pain relief
Midazolam HCI (versed) 100 mg in sodium chloride 0.9 100mL IV infusion at 1mg per hour- helps to sedate patient for comfort from pain and trauma
Hydromorphone (Dilaudid) injection 0.5-1 mg IV every 3 hrs. as needed- treatment for alleviation of pain
Fentanyl (Sublimaze) injection 50-100 mcg IV every 15 mins.- helps to increase pain threshold to tolerate the severe pain experienced by burn patients
Propofol (Diprivan) 10mg/ mL premix infusion, 25mcg/kg/min IV continuous- sedative to induce or maintain anesthesia and/or sedation
Thiamine 100mg x 3 days- provides glycolysis and oxidative decarboxylation of carbohydrates for energy production
Folate 1 mg x 3 days- managing adequate levels of folic acid in order to help reduce toxicity of medication use
8. What are the common criteria used to assess readiness for the initiation of enteral nutrition in burn patients?
The common criteria used to assess readiness for the initiation of enteral nutrition in burn patients is generally based on percentage of TBSA, as well as ensuring that damage to gastrointestinal parts is capable of handling the feeding tube.
9. What are the specialized nutrient recommendations for the enteral nutrition formula administered to burn and trauma patients per ASPEN/SCCM guidelines?
The specialized nutrient recommendation for the enteral nutrition formula administered to burn and trauma patients per ASPEN/SCCM guidelines includes glutamine supplementation, as well as enough protein supplementation.
10. What additional micronutrients will need supplementation in burn therapy? What dosages are recommended?
Ascorbic Acid, Selenium, and Zinc, Vitamin C, Vitamin A, Magnesium, and Calcium are additional supplementations that are used for burn therapy for the loss of nutrients that are common to burn patients.
11. Using Mr. Angelo’s height and admit weight, calculate IBW, % IBW, BMI, and BSA.
IBW = 50 kg + 27.6 kg = 77.6kg
% IBW= (71.2kg x 100) / IBW = 91.75
BMI= (156.64lbs / 72 x 72) x 703 = 21.23
BSA= (182.88 x 71.2)/ 3600 = 3.61
12. Energy requirements can be estimated using a variety of equations. The Xie and Zawacki equations are frequently used. Estimate Mr. Angelo’s energy needs using these equations. How many kcal/kg does he require based on these equations?
Zawacki Equation = 1440kcal/m2/day
Xie Equation EEE = (1000kcal/m2/day) + (25 x BSAB)
13. Determine Mr. Angelo’s protein requirements. Provide the rationale for your estimate.
14. The MD’s progress note indicates that the patient is experiencing acute kidney injury. What is this? If the patient’s renal function continues to deteriorate and he needs continuous renal replacement therapy, what changes will you make to your current nutritional regimen and why?
Acute kidney injury is when the kidney’s filtration process is not functioning optimally. If the patient’s renal function continues to deteriorate and he needs continuous renal replacement therapy, then there may need to be a change in decreasing the amount of feeding that is taking place due to the excessive strain on the kidneys. Additionally protein intake may need to be increased in his case to avoid further protein loss. Higher energy source by way of increased carbs and fats are also recommended for the patient in order to ensure proper healing is taking place. Once he is stabilized there can be a decrease in caloric intake from 2884kcal to 2163kcal.
15. This patient is receiving the medication propofol. Using the information that you listed in question #6, what changes will you make to your nutritional regimen and how will you assess tolerance to this medication?
In order to manage the affects and tolerance of propofol, the patient’s nutritional regimen will be sure to include a sufficient amount of folate to help balance any toxicity that may occur as a result of the propofol.
16. Identify at least 2 of the most pertinent nutrition problems and the corresponding nutrition diagnoses.
The two most pertinent nutrition problems result in hypermetabolic and catabolic responses.
17. Write your PES statement for each nutrition problem.
18. The patient is receiving enteral feeding using Impact with Glutamine @ 60 mL/hr. Determine the energy and protein provided by this prescription. Provide guidelines to meet the patient’s calculated needs using the Xie equation.
19. By using the information on the intake/output record, determine the energy and protein provided during this time period. Compare the energy and protein provided by the enteral feeding to your estimation of Mr. Angelo’s needs.
20. One of the residents on the medical team asks you if he should stop the enteral feeding because the patient’s blood pressure has been unstable. What recommendations can you make to the patient’s critical care team regarding tube feeding and hemodynamic status?
21. List factors that you would monitor to assess the tolerance to and adequacy of nutrition support.
22. What is the best method to assess calorie needs in critically ill patients? What are the factors that need to be considered before the test is ordered?
23. Write an ADIME note that provides your nutrition assessment and enteral feeding recommendations and/or evaluation of the current enteral feeding orders.