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KNH 411: Case Study #29Understanding the Disease and PathophysiologyThe patient has suffered a gunshot wound to the abdomen. This has resulted in an open abdomen. Define open abdomen. The medical record describes the use of a wound “VAC.” Describe this procedure and its connection to the diagnosis for open abdomen.Open abdomen is a strategy used for the management of abdominal emergencies in both traumatic and general surgery situations. The abdominal wall is left open as the result of an injury, because of concern for abdominal compartment syndrome, or because of a significant injury that has produced significant soft tissue defects. A wound VAC promotes wound healing by delivering negative pressure (a vacuum) to the wound site through a dressing. This pressure helps draw the wound edges together, remove infection, and promote the formation of new connective tissue. This system would be ideal to carefully heal and promote the closure of open abdomen. The abdominal tissue would be provided with a unique environment for healing with the removal of infectious materials, reduction of edema, and formulation of new tissues. patient underwent gastric resection and repair, control of liver hemorrhage, and resection of proximal jejunum, leaving his GI tract in discontinuity. Describe the potential effects of surgery on this patient’s ability to meet his nutritional needs.The metabolic stress response to trauma has been described as a progression through three phases: the ebb phase, the flow phase, and finally the recovery or resolution. Define each of these and determine how they may correspond to this patient’s hospital course.The ebb phase defines the period of time immediately after the injury—2-48 hours. This time period is characterized by shock resulting in hypovolemia and decreased oxygen availability to tissues. A decrease in blood volume can result in decreased cardiac output and urinary output. During that time, the hospital would be concerned with restoring blood flow to organs, maintaining oxygenation of all tissues, and stopping any hemorrhaging. The flow phase is characterized by classic signs and symptoms of metabolic stress such as: hypermetabolism, catabolism, and altered immune and hormonal responses. The recovery phase marks a return to anabolism and normal metabolic rate. It is a resolution to the metabolic stress. Based on these phases, a patient’s hospital stay may be largely defined by how quickly they move into recovery phase. (Nelms, pg. 684)Acute-phase proteins are often used as a marker of the stress response. What is an acute-phase protein? What is the role of C-reactive protein in the nutritional assessment of critically ill trauma patients? What other acute-phase proteins may be followed to assess the inflammatory stress response?Understanding the Nutrition TherapyMetabolic stress and trauma significantly affect nutritional requirements. Describe the changes in nutrient metabolism that occur in metabolic stress. Specifically address energy requirements and changes in carbohydrate, protein, and lipid metabolism.Patients experiencing metabolic stress will need to be monitored for protein energy malnutrition (PEM) while taking into account the patient’s health state at the time of arrival to the hospital. Patient’s may progress quickly to PEM if they have any preexisting malnutrition status. Are there specific nutrients that should be considered when designing nutrition support for a trauma patient? Explain the rationale and current recommendations regarding glutamine, arginine, and omega-3 fatty acids for this patient population.Using current evidence-based guidelines, explain the decision-making process that would be applied in determining the route for nutrition support for the trauma patient.Nutrition AssessmentCalculate and interpret the patient’s BMI. BMI = kg/m2 Weight = 102.7 kgHeight = 1.78 mBMI = 32.4 kg/m2 A BMI of 32.4 kg/m2 classifies Mr. Perez as obese. What factors make assessing his actual weight difficult on a daily basis?Mr. Perez’s weight will fluctuate significantly because of changes in fluid balance secondary to fluid resuscitation, losses of fluid from wounds, loss of blood, and edema. (Nelms, pg. 687) Calculate energy and protein requirements for Mr. Perez. Use at least two methods (including the Penn State) to estimate his energy needs. Explain your rationale for using each one. For the Penn State calculation, the minute ventilation is 3.5 L/minute and the maximum temperature is 39.2.American College of Chest Physicians Equation:REE = 25 x weight (kg)REE = 2567 = 2500-2600 kcal/dayPenn State Equation:REE = (0.85 x value from Harris-Benedict Equation) + (175 x Tmax) + (33 x Vo) – 6443REE = (0.85 x 2175 kcal/day) + (175 x 39.20C) + (33 x 3.5 L/min) – 6443REE = 2381 = 2300-2400 kcal/dayHarris Benedict:REE = 66.5 + 13.8W + 5.0S – 6.8A REE = 66.5 + 13.8 x 102.7 kg + 5.0 x 177.8 cm – 6.8 x 29 yearsREE = 2175 kcal/day(Nelms, pg. 688)What does indirect calorimetry measure?Indirect calorimetry is a method used to determine energy expenditure by measuring a patient’s oxygen consumption, carbon dioxide production, and minute ventilation (the amount of air breathed by a patient in one minute). This measurement is especially recommended for critically ill/wounded patients to monitor the adequacy and appropriateness of nutritional support. (Nelms, pg. 244) Compare the estimated energy needs calculated using the predictive equations with each other and with those obtained by indirect calorimetry measurements. Interpret the RQ value. What does it include?What factors contribute to the elevated energy expenditure in this patient? Mr. Perez was prescribed parenteral nutrition. Determine how many kilocalories and grams of protein are provided with his prescription. Read the nutrition consult follow-up and the I/O record. What was the total volume of PN provided that day?Compare this nutrition support to his measured energy requirements obtained by the metabolic cart on day 4. Based on the metabolic cart results, what changes would you recommend be made to the TPN regimen, if any? What are the limitations that prevent the health care team from making significant changes to the nutrition support regimen? The patient was also receiving propofol. What is this, and why should it be included in an assessment of his nutritional intake? How much energy did it provide? The RD recommended that trickle feeds be initiated. What is this and what is the rationale? The RD recommended the formula Pivot 1.5 for these trickle feeds. What type of formula is this, and what would be the rationale for choosing this formula?List abnormal biochemical values for 3/29, describe why they might be abnormal, and explain any nutrition-related implications.Current guidelines recommend using a nitrogen balance study to assess the adequacy of nutrition support. According to the Powell (2012) article, what adjustments should be made to assess for nitrogen losses through fistulas, drains, or wound output?A 24-hour nitrogen collection is completed for Mr. Perez with results of UUN 42 g. Calculate his nitrogen balance.Nutrition DiagnosisIdentify the nutrition diagnosis you would use in your follow-up note. Complete the PES statement. (Nelms, pg. 688)Nutrition InterventionFor the PES statement that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology).Nutrition Monitoring and Evaluation What are the standard recommendations for monitoring the nutritional status of a patient receiving nutrition support?Hyperglycemia was noted in the laboratory results. What is hyperglycemia of concern in the critically ill patient? How was this handled for the patient?What would be the standard guidelines and subsequent recommendations to begin weaning TPN and increasing enteral feeds? ................
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