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
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Slide1
Nutrition Care Process:Gunshot Wound to the Abdomen
Hailey Koch
Northbay
Medical Center
June 3, 2014
Slide2OverviewBackground of PatientMetabolic Stress Response (Trauma)
Physician’s Assessment
Nutrition Assessment
Nutrition Diagnosis
Nutrition Prescription
Nutrition Intervention
Monitoring/Evaluation
Colostomy Nutrition Management
Slide3Background 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
Slide4GSW Depiction
Slide5GI SurgeryExploratory Laparotomy
Partial
Colectomy
& Colostomy
Photo Courtesy of http://
www.med.nyu.edu
/contentChunkIID
=100983
Slide6Metabolic 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
Slide7Physiologic Response to StressEbb Phase: 2-48 hr post-injuryShock resulting in hypovolemia
Decreased O
2
available to tissues
Decreased
cardiac
and
urinary
output
Slide8Physiologic 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
Slide9Physiologic 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
Slide10Physiologic Response to Stress
Slide11Physiologic 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)
Slide12Summary 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
Slide13Nutrition Assessment in StressSocial & Medical HistoryFood/Nutrition Related HistoryAnthropometric Measurements
Biochemical Data
Medical Tests & Procedures
Slide14Social & 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)
Slide15Food & 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
Slide16Admission 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
Slide17Admission 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%
Slide18Medical 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
Slide19Nutrition 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
Slide20OverviewBackground of PatientMetabolic Stress Response (Trauma)
Physician’s Assessment
Nutrition Assessment
Nutrition Diagnosis
Nutrition Intervention
Monitoring/Evaluation
Slide21Physician’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
Slide22Nutrition 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
Slide23Nutrition 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
Slide24Nutrition 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
Slide25Nutrition 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
Slide26While 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)
Slide27While 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
Slide28Nutrition 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
;
%
Slide29Nutrition 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)
Slide30Physician’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
Slide31Nutrition 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
Slide32Nutrition 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
Slide33TPN 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
Slide34TPN 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
Slide35Follow-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
Slide36Follow-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
Slide37Follow-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
Slide38Summary 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
Slide39Nutrition 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
Slide40OverviewBackground of Patient
Metabolic Stress Response (Trauma)
Physician’s Assessment
Nutrition Assessment
Nutrition Diagnosis
Nutrition Prescription
Nutrition Intervention
Monitoring/Evaluation
Colostomy Nutrition Management
Slide41Colostomya procedure in which the rectum
only
is surgically removed, and the end of the colon is attached to the stoma
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
Slide43Colostomy: 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
Slide44Conclusion 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
Slide45Questions??
Slide46Thank you to the dietitians at NBMC for their guidance & instruction
Slide47ReferencesAcademy of Nutrition and Dietetics. (2014). Colostomy Nutrition Therapy.
Arabi, Y.M
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,
Dabbagh, O.C
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Tamim, H.M
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Al-Shimemeri, A.A
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Memish, Z.A
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Haddad
, S.H
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Giridhar, H.R
.,
Rishu, A.H
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Al-Daker, M.O
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Kahoul, S.H
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Britts
, R.J
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Sakkijha, M.H
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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
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Haupt
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Slide48ReferencesGreen, 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.
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, K.R. (2013). Energy estimation in the critically ill: a literature review.
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Clinical
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McClave
, S.A., Martindale, R.G.,
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Enteral
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Nelms
, M.,
Sucher
, K.P., Lacey, K., Long Roth, S. (2011). Metabolic stress and the critically ill. In Y.
Cossio
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Nutrition Therapy &
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Sauerwein
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van
Schijndel
R.J. (2007). Perspective: How to evaluate studies on
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