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Slide1

Nutrition Care Process:Gunshot Wound to the Abdomen

Hailey Koch

Northbay

Medical Center

June 3, 2014

Slide2

OverviewBackground of PatientMetabolic Stress Response (Trauma)

Physician’s Assessment

Nutrition Assessment

Nutrition Diagnosis

Nutrition Prescription

Nutrition Intervention

Monitoring/Evaluation

Colostomy Nutrition Management

Slide3

Background 27 y.o. male (RENO)

Admitted to ER with Gunshot Wound to Abdomen and L. Wrist

May 1, 2014 @ 7:30 pm

Awake and alert when admitted

PMH: Asthma, GSW to L. Wrist 2006

Taken to OR for exploratory

laparotomy

, partial

colectomy

w

/ Hartman’s pouch & colostomy, and bladder repair

Transferred to ICU

Slide4

GSW Depiction

Slide5

GI SurgeryExploratory Laparotomy

Partial

Colectomy

& Colostomy

Photo Courtesy of http://

www.med.nyu.edu

/contentChunkIID

=100983

Slide6

Metabolic Stress (Trauma)Def: Hypermetabolic, catabolic response to acute

injury

or disease

The physiologic response to stress can be divided into three phases:

Ebb phase

Flow phase

Recovery phase

Slide7

Physiologic Response to StressEbb Phase: 2-48 hr post-injuryShock resulting in hypovolemia

Decreased O

2

available to tissues

Decreased

cardiac

and

urinary

output

Slide8

Physiologic Response to StressFlow Phase: 3-10 daysHemodynamically

stabilizing

Hypermetabolism

Catabolism

Altered immune and hormonal response

Recovery Phase: 10-60 days

Resolution of stress

Return to anabolism

Normal metabolic rate

Slide9

Physiologic Response to Stress“Fight or Flight” Response

Goal:

mobilize nutrient stores to meet immediate energy demand

Glucagon: Stimulate gluconeogenesis

Promote protein catabolism

Cortisol : Stimulate gluconeogenesis

Free fatty acid mobilization

Increase skeletal muscle catabolism

Catecholamines:

Glycogenolysis

Increase fatty acid release

Slide10

Physiologic Response to Stress

Slide11

Physiologic Response to StressAcute Phase Proteins:Markers of Stress Response

Positive

v

. Negative

Fibronectin

C-reactive protein (CRP)

Ceruloplasmin

Albumin

Pre-albumin

Regulated by:

Cytokines

Interleukins

Leukotrienes

Interferon

Tumor Necrosis factor (TNF)

Slide12

Summary of Metabolic AbnormalitiesIncreased levels of glucagon, cortisol, catecholamines

Hyperglycemia & insulin resistance

Increased BMR

Increased rate of gluconeogenesis

Catabolism of skeletal muscle

Increased urinary nitrogen excretion (negative nitrogen balance)

Increased synthesis of + acute phase proteins

Decreased synthesis of – acute phase proteins

Slide13

Nutrition Assessment in StressSocial & Medical HistoryFood/Nutrition Related HistoryAnthropometric Measurements

Biochemical Data

Medical Tests & Procedures

Slide14

Social & Medical HxMarried w

/ two young

children

Lives

w

/ wife, children and

mother

GSW

occurred

in park while playing basketball w/ sonPMH of asthma, GSW to left wrist in 2006, Schizophrenia

No known surgical

hx

No known drug or food allergies

Family medical

hx

of mental illness (unspecified)

Slide15

Food & Nutrition Related HxPt had good appetite and adequate intake PTAWife is main meal preparer

Meal pattern consists of no breakfast, medium lunch and large dinner

Food preferences include sandwiches, tacos, milk, and canned fruits

No nutrition-related medications PTA

Risperidone

d/c

5 years ago

Slide16

Admission Anthropometric DataHt: 175.3 cm (5’8”)

Wt

(Admit):

90.9 kg

(200#)

UBW

:

93.1

kg

(205#)ABW: 80 kg IBW: 73 kg

%IBW: 137%

BMI: 32.51 kg/m

2

Slide17

Admission Biochemical Data

Lab

Value

Normal

Range

Glucose

66 mg/

dL

Low

70-110 mg/

dL

Creatinine

1.7 High

0.7-1.2 mg/

dL

Na

(Sodium)

143

136-145

mmol

/L

K

(

Potassium)

2.5 Low (critical)

3.3-5.1

mmol

/L

Chloride

105

98-107

mmol

/L

Lactic Acid

3.9 High

0.5-2.2

mmol

/L

Platelets

266

30-400

10

3/uL

Hgb/Hct

14.1/41.9 Low

13.3-16.5

g/dL

, 40-50%

Slide18

Medical Tests & Procedures DX Chest 1 View, DX Pelvis LimitedCT Abdomen, Wrist X-Ray CompleteFAST Ultrasound

Bladder Repair

Partial

colectomy

w

/ Hartmann’s pouch

Colostomy

Repair of comminuted fracture in L. Wrist

Slide19

Nutrition InterventionsInitiate nutrition support within 24-48 hrs of admissionPlan for

Enteral

Nutrition if feeding route feasible

Plan

for

Parenteral

Nutrition via Peripheral or Central route if EN not feasible

Early feeding post-op will prevent further protein catabolism & meet increased energy needs

Slide20

OverviewBackground of PatientMetabolic Stress Response (Trauma)

Physician’s Assessment

Nutrition Assessment

Nutrition Diagnosis

Nutrition Intervention

Monitoring/Evaluation

Slide21

Physician’s Assessment (5/2)Status post-GSWs

LLQ abdomen

w

/ exit wound at

perirectal

area

L. wrist

w

/ displace R. radial

styloid fracture

Acute Renal Failure

Electrolyte Imbalance

Uncontrolled HTN

Hematuria

& some

pyuria

, 2° to bladder injury

Slide22

Nutrition Assessment (5/2)Anthropometrics & Physical Ht: 175.3 cm Wt: 90.9 kg

UBW: 93.1 kg ABW: 80 kg

IBW: 73 kg %IBW: 137%

BMI: 32.51 kg/m

2

Ventilator dependent

Sedated on Propofol post-surgery

Physical appearance – muscular build

Slide23

Nutrition Assessment (5/2)Biochemical

Value

Normal Range

Units

Na

139

136-145

mmol

/L

K

4.6

3.3-5.1

mmol

/L

BUN

9

8-26

mg/

dL

Creatinine

1.4 High

0.7-1.2

mg/

dL

Glucose

147 High

70-110

mg/

dL

Albumin *

--

3.5-5.0

gm/

dL

Phosphorus

--

2.3-4.7

mg/

dL

Mg

--

1.5-2.5

mg/

dL

Hgb/Hct

**

9.6/27 Low

13.3-16.5/40-50

g/dL

;

%

*Value not available for Albumin, however value for Calcium low (6.6) which may be indicative of low albumin

**Value for H&H consistent

w

/ significant blood loss estimated at

1750 ml

Slide24

Nutrition Assessment (5/2)Estimated Energy Requirements

Nutrient

Needs

Formula

Calorie

2800-3200 kcal

35-40 kcal/kg

ABW

Protein

104-120

g

1.3-1.5

g

/kg ABW

Fluid

2400-2800

ml

30-35 ml/kg ABW

*based off ABW

Slide25

Nutrition Diagnosis& Intervention (5/2)PES:

Inadequate protein, energy intake

r/t

altered GI function

d/t

GSW AEB unable to meet needs as pt is NPO and in surgery this day

Plan:

Continue NPO and discuss nutrition POC

w

/ MD. Will recommend EN when feasible; Propofol will provide ~150 kcal/day

Slide26

While You Were Out…Saturday 5/3:Weaned off ventilator,

extubated

Weaned off Propofol

Abdomen: soft, non-tender, BS present

Physician’s Assessment

Post trauma day #2, Post-op day #1

Acute blood loss anemia

Respiratory failure 2° to massive transfusion

Plan

PPN started @

100

ml/hr

x

14 hr (1470 kcal, 70 g pro)

Slide27

While You Were Out…Sunday 5/4L. wrist fracture repair

BP stable;

Hgb

decreased and received transfusion

Abdomen: soft,

nontender

, BS present

Physician’s Assessment

S/P

GSWsAcute Respiratory Failure – now

extubated

Likely Aspiration

Pneumonitis

– now improved

Plan

NPO at this time

Slide28

Nutrition Assessment (5/3 & 5/4)Biochemical

5/3

5/4

Normal Range

Units

Na

141

140

136-145

mmol

/L

K

3.5

3.4

3.3-5.1

mmol

/L

BUN

7

8

8-26

mg/

dL

Creatinine

1.1

0.9

0.7-1.2

mg/

dL

Glucose

127 high

144 high

70-110

mg/

dL

Albumin *

2.1 low

2.0 low

3.5-5.0

gm/

dL

Phosphorus

2.0 low

1.7 low

2.3-4.7

mg/

dL

Mg

--

1.8

1.5-2.5

mg/

dL

Hgb/Hct

8.1/23.3 low

7.9/22.2

low

13.3-16.5/40-50

g/dL

;

%

Slide29

Nutrition Assessment (5/5)Anthropometrics & PhysicalHt: 175.3 cm Wt: 90.9 kg

Currently on TPN via PICC line

Post-op changes

w

/

colostomy

Hypoactive BS, No BM or flatus

Awaiting return of bowel function

NG output green/bilious and increasing

80 ml (5/3), 920 ml (5/4)

Slide30

Physician’s Assessment S/P GSWs

HTN

Anemia – stable

w

/ transfusion;

d/t

blood loss

Mild

hypokalemia

– replacedS/P acute respiratory failure – off ventilatorPlan:

Pain control

Continue TPN 1-2 days

Increase physical activity

Slide31

Nutrition Assessment (5/5)Biochemical

Value 5/5

Normal Range

Units

Na

140

136-145

mmol

/L

K*

3.4

3.3-5.1

mmol

/L

BUN

9

8-26

mg/

dL

Creatinine

0.8

0.7-1.2

mg/

dL

Glucose

158

70-110

mg/

dL

Albumin*

1.9 low

3.5-5.0

gm/

dL

Phosphorus*

2.1 low

2.3-4.7

mg/

dL

Mg

2.4

1.5-2.5

mg/

dL

Hgb/Hct

11.8/34.3 low

13.3-16.5/40-50

g/dL

;

%

*Refeeding syndrome unlikely on PPN; electrolyte losses likely

r/t

surgery, fluid losses via NG, and surgical drains

Slide32

Nutrition Diagnosis & Intervention (5/5)PES: Inadequate protein, energy intake

r/t

altered GI function

d/t

GSW AEB pt is on TPN @ 75 ml/hr providing 1890 kcal, 90

g

pro which meets 68% kcal and 87% pro needs

Plan:

Recommend TPN nutrition change

Will recommend advance TPN rate to 100 ml/hr (2520 kcal, 120 g

pro)

EN contraindicated at this time

TPN to continue next 1-2 days

Slide33

TPN RecommendationD25, AA 5% @ 100 ml/hr + 250 ml 20% lipid

Provides: 2520 kcal, 120

g

pro, 2650 ml

fld

(2040 Kcal CHO, 480 Kcal protein, 500 Kcal fat)

Check:

Glucose infusion rate (4-6 mg/kg/min):

4.6 mg/kg/min

Monitor:

Glucose, Electrolytes

Slide34

TPN Recommendation

Nutrient

Estimated Requirements

TPN Provides

Calorie*

2800-3200 kcal

2520 kcal

Protein

104-120

g

120

g

pro

Fluid

2400-2800 ml

2650 ml

Slide35

Follow-Up 5/6TPN Advanced to 100 ml/hr to provide 2520 kcal, 120 g pro

NG output is minimal, slightly green

Colostomy output is minimal serous fluid

No BM, flatus

Goal:

meet

est

needs via TPN

Plan:

when colostomy output occurs, start oral diet and d/c NG tube

Slide36

Follow-Up 5/7Pt tolerating TPN @ advanced rate of 100 ml/hr (2520 kcal, 120 g

pro)

Pt given 250 ml 20% lipid this day to provide 500 kcal

Some colostomy output, increased BS, no flatus

Goal:

Meet

est

needs via nutrition support

Tolerate clear liquid diet

Plan:d/c

NG tube and start clear liquid diet

Continue TPN for 1+ day and

d/c

if pt tolerating oral diet

Reglan

IV

q

6 hr 10 mg

Slide37

Follow-Up 5/8Ht: 175.3 Wt: 101.4 kg UBW: 93.1 kg (stated)

Pt transitioned from clear liquid to soft/low residue diet

Finishing TPN administered on 5/7

Colostomy functioning

w

/ stool present; BS present

Goal:

Meet

est

needs via PO intake >75%Plan: monitor tolerance of soft diet

d/c

TPN after current bag

discharge education

Slide38

Summary PPN started @ 100 ml/hr

x

14 hr (1470 kcal, 70

g

pro)

TPN @ 75 ml/hr

x

24 hr (1890 kcal, 90

g

pro)

TPN @ 100 ml/hr

x

24 hr ( 2520 kcal, 120

g

pro)

Clear Liquid

+

Finish TPN @ 100 ml/hr

Soft/Low Residue

Slide39

Nutrition Interventions: EducationPurpose of TPNDiet advancementClear liquid to Soft/low residue

Nutrition Management for Colostomy

Visual & verbal instruction

Customizing diet

Follow-up on adequacy of intake

Slide40

OverviewBackground of Patient

Metabolic Stress Response (Trauma)

Physician’s Assessment

Nutrition Assessment

Nutrition Diagnosis

Nutrition Prescription

Nutrition Intervention

Monitoring/Evaluation

Colostomy Nutrition Management

Slide41

Colostomya procedure in which the rectum

only

is surgically removed, and the end of the colon is attached to the stoma

Slide42

Colostomy: Nutritional ManagementGoals:Avoiding digestive problems such as diarrhea & constipation

Identifying and limiting consumption of foods that cause gas & odor

Choosing foods that will promote normal bowel function

Plan:

Soft/low residue diet

Small frequent meals

Adequate hydration

Slide43

Colostomy: Nutritional ManagementTips for Success:Small bites, chew thoroughly

SMFs

at same time each day

Avoid spicy or fried foods or those high in sugar

Some odor-causing foods include onions, eggs, fish, broccoli and cabbage

Some gas-causing foods include beans & cruciferous vegetables

Stool thickening foods include banana, pasta, rice, applesauce

Slide44

Conclusion Traumatic multiple GSW resulting in metabolic stress response and subsequent colon resection & colostomy

Nutrition interventions initiated by MD and challenged by dietetic intern to deliver appropriate MNT

Nutrition education provided throughout hospital stay to inform family & patient of diet progress

Recovery & healing is now the responsibility of the family & patient

Slide45

Questions??

Slide46

Thank you to the dietitians at NBMC for their guidance & instruction

Slide47

ReferencesAcademy of Nutrition and Dietetics. (2014). Colostomy Nutrition Therapy.

Arabi, Y.M

.

,

Dabbagh, O.C

.,

Tamim, H.M

.,

Al-Shimemeri, A.A

.,

Memish, Z.A

.,

Haddad

, S.H

., Syed, S.J

.,

Giridhar, H.R

.,

Rishu, A.H

.,

Al-Daker, M.O

.,

Kahoul, S.H

.,

Britts

, R.J

.,

Sakkijha, M.H

. (2008). Intensive versus conventional insulin therapy: a

randomized

controlled trial in medical and surgical critically ill patients.

Critical

Care

Medicine, 36, 3190-7.

Dickerson, R.N. (2011). Optimal caloric intake for critically ill patients: first, do no

harm

.

Nutrition in Clinical Practice, 26, 48-54.

Gallo, F.,

Haupt

, E.,

Devoto

, G.L.,

Marchello

, C.,

Garbarini

, R., Bravo, M.F.,

Boicelli

,

R

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Deiana

, F.,

Racchi

, O. (2011). Seriate

prealbumin

and C-reactive protein

measurements in monitoring nutritional intervention in hospitalized patients: a prospective observational study. Mediterranean Journal of Nutrition and Metabolism, 4, 191-195.

Slide48

ReferencesGreen, D.M., O’Phelan, K.H.,

Bassin

, S.L., Chang, C.W., Stern, T.S.,

Asai

, S.M. (2010). Intensive versus

conventional

insulin therapy in critically ill neurologic patients.

Neurocrit

Care, 13, 299-306

.Maday

, K.R. (2013). Energy estimation in the critically ill: a literature review.

Universal Journal of

Clinical

Medicine, 3, 39-43.

McClave

, S.A., Martindale, R.G.,

Vanek

, V.W., McCarthy, M., Roberts, P., Taylor, B., Ochoa, J.B.,

Napolitano

, L.,

Cresci

, G. (2009). Guidelines for the provision and assessment of nutrition support

therapy

in the adult critically ill patient.

Journal of

Parenteral

and

Enteral

Nutrition, 33, 277-316.

Nelms

, M.,

Sucher

, K.P., Lacey, K., Long Roth, S. (2011). Metabolic stress and the critically ill. In Y.

Cossio

& P. Williams (Eds.),

Nutrition Therapy &

Pathophysiology

(683-691). California: Wadsworth.

Sauerwein

H.P.,

Strack

van

Schijndel

R.J. (2007). Perspective: How to evaluate studies on

peri

- operative

nutrition? Considerations about the definition of optimal nutrition for patients and its

key

role in the comparison of the results of studies on nutritional intervention.

Journal of Clinical

Nutrition

, 26, 154-158.

Smith, D.M.,

Loewenstein

, G.,

Ubel

, P.A. (2007). Sensitivity to disgust, stigma and adjustment to life with a colostomy. Journal of Research in Personality, 41, 787-803.

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Nutrition Care Process: Gunshot Wound to the Abdomen - Description


Hailey Koch Northbay Medical Center June 3 2014 Overview Background of Patient Metabolic Stress Response Trauma Physicians Assessment Nutrition Assessment Nutrition Diagnosis Nutrition Prescription ID: 780025 Download

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