Patient Summary: Mr. Angelo is a 65-year-old male admitted as a level 2 trauma with 40% total body surface area burns after being involved in a trailer fire
Patient Summary: Mr. Angelo is a 65-year-old male admitted as a level 2 trauma with 40% total body surface area burns after being involved in a trailer fire. He is admitted to the surgical intensive care unit for management of burn injury. The burn involves the face, bilateral upper extremity, bilateral lower extremity circumferentially, scrotum, back, and buttocks. The ENT service evaluated the patient and performed a naso- pharyngolaryngoscopy. Findings included laryngeal edema and soot on the vocal cords bilaterally. Recommendation is to intubate for airway protection. Patient does have occasional wheezing and some patchy infiltrates on chest X-ray that could be re-lated to smoke inhalation. Pt was started on fluid resuscitation per Parkland formula using lactated Ringer’s (LR)@610 mL/hr. He received
1650cc
of normal saline. History: Medical history: Diabetes, HTN, GERD Surgical history:
s/p
cholecystectomy 30 years ago Medications at home: None Tobacco use: Smokes 1 PPD for
.30
yrs. Alcohol use:
2−3
beers daily and a case on Saturday and Sunday Family history: Father: HTN; mother: anxiety disorder, HTN; brother: healthy Demographics: Year ‘s education: 11 Language: English only Occupation: Unemployed Household members: Lives alone Ethnicity: Caucasian Religious affiliation: Unknown Primary Assessment per EMS: Airway: Intact Breathing: Clear Circulation 21 carotid and radial pulses, 21 femoral, 11 DP pulses diminished Glasgow coma score: 14 Admitting History/Physical: General appearance: Alert, cooperative, mild distress, appears stated age. The wounds appear to have ruptured blisters and devitalized skin. The patient’s ROM to affected area is diminished in range with pain. Vital Signs: Temp: 37. BP: 140/93 Pulse: 120 Resp rate:
22.
SpO2
:98%
Weight:
71.2 kg
Height:
175 cm
HEENT: Head/Face: Non-rebreather mask in place. Burns involving entire face, singed eyebrows, hair, and facial hair. Eyes: PERRLA Ears: Clear Nose: Soot noted in nares and oropharynx Throat: Dry mucous membranes Neck: C-collar in place Lungs: Clear to auscultation bilaterally Heart: Tachycardia, regular rhythm; S1, S2 normal, no murmur, click, rub, or gallop Abdomen: Soft, skin tender. Bowel sounds normal. No masses, no organomegaly, partial thickness and 1st degree burns near umbilicus. Upper extremities: Burns noted R bicep, forearm, hand, left bicep and hand, mostly second degree. Skin sloughing and devitalized tissue. Lower extremities: Mostly full thickness burns noted to bilateral lower extremities circumferentially Back: Second degree burns in mid and left back Genitourinary: Erythema and blistering at head of penis and scrotum Peripheral vascular: Pulsesent 21 , POP: present 21 , DP: present Right pulses: FEM: present 21 , POP: present 21 DP: present 11, PT: Left present Admission Orders: Laboratory:
C
-reactive protein now and routine every Monday morning CBC, EDIF, platelet routine every morning Chem 7, IP, Mg, Ca routine every morning Hemoglobin
AlC
routine one time Hepatic function panel routine, every Monday morning Prealbumin now and routine every Monday morning Ionized calcium routine every morning PT, IR, PTT routine every morning ABGs routine every morning Radiology: CT head, neck, abdomen KUB-NG placement and enteral feeding tube placement verification Chest X-ray for CVC placement and ET tube Vital Signs: Routine, every 1 hour I &
O
recorded every hour NG tube to low intermittent suction Oral care per ventilator protocol: Oral mouth swab every 4 hours and PRN. Teeth and gum brushing every 12 hours. Supraglottic oral suctioning every 8 hours and prior to manipulation of the ETT. Diet: NPO with EN. Impact with Glutamine@20 mL/hr, advance
20 mL/hr
every 4 hours to
60 mL/
hr. Final goal rate per RD. Impact formula information: Scheduled and PRN Medications: Ascorbic acid
500mg
every 12 hours Chlorhexidine
0.12%
oral solution
15 mL
every 12 hours Famotidine tablet
20mg
every 12 hours Heparin injection 5,000 units every 8 hours Insulin regular injection every 6 hours Multivitamin tablet 1 tab daily Zinc sulfate
220mg
daily Methadone
5mg
every 8 hours Oxandrolone
10mg
every 12 hours Senna tablet
8.6mg
daily Docusate oral liquid
100mg
every 12 hours Silver sulfadiazine
1%
cream topical application daily Midazolam HCl (Versed)
100mg
in sodium chloride
0.9%
100 mL
IV infusion, initiate infusion at
1mg/hr
Hydromorphone (Dilaudid) injection
0.5−1mg
, intravenous every 3 hours as needed Fentanyl (Sublimaze) injection 50-100 mcg intravenous every 15 minutes as needed Propofol (Diprivan)
10mg/mL
premix infusion, start at 25
mcg/kg/min
intravenous continuous Thiamin
100mg33
days Folate
1mg33
days IVF: LR@610 mL/hr
×
first 8 hours and decrease to 305
mL/hr×16
hours Nutrition: NPO with TF Impact with Glutamine@60 mL/hr. History: Not following any specific diet. Stable weight for past 6 months. Has not been monitoring blood glucose levels for about a year. MD Progress Note: 9/11 0500 Subjective: 65-yo male who presented as level 1 trauma with
40%
total body surface area burns. Intubated on arrival to SICU for airway protection. Plan per burn team to do bronchoscopy at 11:30 today. Patient with significant respiratory acidosis. S/P escharotomy of bilateral lower extremities overnight per trauma team. Hypotensive overnight. Received
4 L
of fluids. Principal Problem: Burn involving
40%
body surface area Active problems: Respiratory failure Acute pain due to injury Oliguria Malnutrition Vitals: Temp: 100.2 Pulse: 104 Resp. rate: 18 BP: 87/59 O2 Sat (%)
100%
Fluid Management ( 24 hours): L/O last 3 completed shifts In:
16425 mL
Out:
1696 mL
Urine output:
1295 mL(18 mL/kg)
Physical Exam: General appearance: Intubated, sedated Head: Burns involving entire face, singed eyebrows, hair, and facial hair Back: Partial thickness burns over lower back and buttocks Lungs: Clear to auscultation bilaterally Heart: Tachycardia, regular rhythm; S1, S2 normal, no murmur, click, rub, or gallop Abdomen: Soft, non-tender. Bowel sounds normal. No masses, no organomegaly, partial thickness and 1st degree burns near umbilicus. Male genitalia: Abnormal findings: blistering over scrotum and head of penis Extremities: Partial thickness burns to bilateral upper extremities and full thickness circumferential burns to lower extremities. S/P escharotomy of bilateral lower extremities. Assessment/Plan:
40%
TBSA burn: Managed per burn team. Continue daily dressing changes. OR today for debride- ment and split thickness skin grafting. Respiratory failure: Intubated
9/9
for airway protection. Bronchoscopy at 11:30 today. Pain: Versed gtt, increase methadone to
10mg
every 8 hours. Dilaudid and fentanyl pm. Wean propofol to off possibly by the end of the day. Currently at
25 mL/hr
. Hyperkalemia: Secondary to metabolic, respiratory acidosis. Improving. Last K15.9. Continue to resuscitate with LR. Protein-calorie malnutrition: Advance TF to goal rate per nutrition. Acute kidney injury: Continue fluid resuscitation. Burns are often described as one of the most metabolically stressful injuries. Discuss the effects of a burn on metabolism and catabolism and how this will affect nutritional requirements. II. Understanding the Nutrition Therapy Using evidence-based guidelines, describe the potential issues of nutrition care in burn patients? What additional micronutrients will need supplementation in burn therapy? III. Nutrition Assessment Using Mr. Angelo’s height and admit weight, calculate IBW,
%
IBW, BMI, and BSA How many
kcal/kg
does he require ? Determine Mr. Angelo’s protein requirements? What is the fluid requirement for Mr Angelo? Why we need to administrate fluid immediately? IV. Nutrition Diagnosis Identify at least two of the most pertinent nutrition problems and the corresponding nutrition diagnoses. Write your PES statement for each nutrition problem. Nutrition Monitoring and Evaluation List factors that you would monitor to assess the tolerance to and adequacy of nutrition? What are the factors that need to be considered to meet the metabolic demands for
Mr
angelo? ( nutrition goal for Burn patient) What do you think is the best feeding rout for patient with burn, and what is the alternative feeding rout we can used?
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