1. Name(s): Carole Matadamas, Michael Leclerc, Laurie Hill
Date: February 26, 2015
Class period: Tuesday/Thursday 9:00am Section 16289
NTR 444
Due: On the date stated in your syllabus by 11:59 pm via Blackboard
Case Study #29 – Metabolic Stress and Trauma
Understanding the Disease and Pathophysiology
1. (1 point – one paragraph) The patient underwent gastric resection and repair, control
of liver hemorrhage, and resection of proximal jejunum, leaving his GI tract in discontinuity.
Describe the potential effect of surgery on this patient’s ability to meet his nutritional needs.
The potential effect of surgery for this patient is that they will not absorb important nutrients
that are regularly absorbed by the jejunum. This could potentially cause nutrient
deficiencies, which could lead to health problems and putting the patient at a greater risk for
disease.
2. (1 points – one paragraph) 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 the surgical procedure where an incision is made into and through the
abdominal cavity wall. This procedure is done in order to assess and control any damage
related to hemorrhaging and/or gastrointestinal contamination. The incision is then
temporarily closed and can be reopened, allowing access to make the further needed
repairs to the region.
A wound VAC is a system/method which uses negatively applied (vacuum) pressure to help
close a wound. This method helps to remove excess fluids, as well as inhibitors to wound
healing, from the wound area. This method increases/accelerates the formation of new
granulated cells and production of extracellular matrix materials.
A sponge type material is fitted, placed, and then sealed over an open wound. A small
vacuum tube is then partially inserted into the sponge-like material and turned on. The
wound heals and closes over time without the use of stitches, staples, or glues, and would
be open until further into the healing process.
3. (3 points) The metabolic stress response to trauma has been described as a
progression through three phases: ebb phase, flow phase and recovery or resolution phase.
Define these three phases and how they may correspond to this patient’s hospital course.
The ebb phase typically occurs within 2-48 hours post-injury, and is characterized by
hypovolemia, decreased cardiac output, lowered body temperature, and hypoxia. The
priority at this stage is the hemodynamic stabilization of the patient.
The acute or flow phase occurs following the ebb phase, hyperglycemia results from high
glucagon, cortisol, and epinephrine levels, increased gluconeogenesis from total body
protein catabolism, increased glycogenolysis and insulin resistance. This stage is also

2. characterized by an increase in positive acute phase proteins such as C-reactive protein,
and a decrease in negative acute phase proteins albumin and prealbumin. If the patient
remains in this state too long, they have an increased risk of multi- organ failure and death.
The adaptive flow phase that follows is a return to anabolic processes. Blood glucose
levels, metabolic rate, and hormone levels begin to normalize. The method by which
nutrition support is given depends on multiple factors, including the nature of the patient’s
injury, GI function, and whether or not PO intake is one of the many options available. The
patient must first be hemodynamically stable before nutrition support is initiated.
4. (1 points- one paragraph) What is an acute phase protein? What is the role of C-
reactive protein in the nutritional assessment of critically ill trauma patients?
Acute phase proteins are proteins that increase or decrease by at least 25% as a response
to trauma. C-reactive protein is a positive acute phase protein, meaning its concentration
increases during a stress response. Because of its extremely short half-life, a decrease in
c-reactive protein is looked for as a sign of stabilization in the critical patient.
Nutrition Assessment
5. (1 point) Calculate and interpret the patient’s BMI. What factors make assessing his
actual weight difficult on a daily basis?
Weight (kg)/ (Height in meters)^2
102.7 kg / 3.16 m
BMI = 32.5 kg/m^2
According to the patient’s BMI of 32.5kg/m^2, he would fall into the category of obese class
I. It is difficult to assess the patient’s actual weight on a daily basis because he is in critical
condition and experiencing severe inflammation accompanied by fluid retention and
draining as well as continued hemorrhaging.
6. (2 points) What does indirect calorimetry measure? Interpret the RQ values?
Indirect calorimetry measures energy expenditure and calculates needs by measuring the
increase in the amount of carbon dioxide expired and the decrease in the amount of oxygen
expired from the amount that was present in the inhaled air. The RQ is calculated as
VCO2(mL/min) / VO2(mL/min), it is a means of determining metabolic macronutrient or
substrate usage.The RQ for the patient is 0.76 and reflects fat as the main source of fuel
being metabolized, a mixed diet would have an RQ of 0.85, CHO 1.0, Protein 0.8-0.82,
Alcohol 0.67, Ketosis <0.60, Lipogenesis 1.01-1.2, and hyperventilation would result in an
RQ >1.1.
7. (2 points) The patient was also receiving propofol. What is this, and why should it be
included in an assessment of his nutritional intake?
Propofol is a lipid based anesthetic used during surgeries and in intensive care units to
induce a sleep state in patients. It should be included in the nutritional assessment due to
its lipid content which significantly adds to lipid and total energy (kcal) intake. If the Propofol
is not included in the nutrition assessment the intake of lipids and total energy would be
much higher than calculated and the risk of complications from overfeeding would increase.

3. 8. (2 points) The RD recommended that trickle feeds be initiated. What is this and what
is the rational?
Trickle feeds are enteral feedings that are administered at a very reduced rate that will not
meet nutritional needs. The rationale for the trickle feeding is to stimulate mucosal repair
and growth, maintain gut tissue health, prevent bacterial translocation, and reduce chances
of cholestasis.
9. (4 points) List abnormal biochemical values and describe why they might be
abnormal.
Biochemicl
Value
Patient’s
Value
(Indicate high
or low)
Reason for Abnormality Nutrition Implication
BUN (mg/dL) 25 (high) Increased catabolism of (LBM)
protein, internal bleeding.
Increased protein needs.
Glucose (mg/dL) 140 (high) HbA1C values are also high (7.1)
indicating a history of elevated
blood glucose related to Diabetes
Mellitus.
May need to adjust formula
ratios and/or insulin dosages
to reduce levels of
hyperglycemia.
Magnesium
(mg/dL)
1.5 (low) Increase in anabolic activity. Magnesium intake should be
increased to avoid
complications of
hypomagnesemia.
Alkaline
Phosphatase
(U/L)
540 (high) Bile accumulation due to lack of
enteral stimulation.
Initiation of trickle feed will
increase enteral stimulation.
Nutrition Monitoring and Evaluation
10. (2 points) List 4 standard recommendations for monitoring the nutritional status of a
patient receiving nutrition support.
1) Nutrient intake/output should be monitored daily until patient is medically and/or
nutritionally stable. Subsequent monitoring should be done weekly.
2) Blood Glucose should be monitored 3 times a day until patient is stable, then every 1-2
week.
3) Weight should be monitored daily, once stable monitoring should be done weekly.
4) Hydration/fluid status should be monitored daily until patient is stable, monitoring should
be done 3 times a week once stable.
11. (1 points) Hyperglycemia was noted on the patient care monitoring sheet. Why is
hyperglycemia of concern in the critically ill patient? How was this handled for this patient?
Hyperglycemia is a concern in the critically ill patient because patients in this state are
experiencing a great deal of metabolic stress and trauma that can result in a hypermetabolic

4. state and with increasing insulin insensitivity. Patients in this state are catabolizing lean
body mass to fuel gluconeogenesis as their source of glucose instead of conserving the
proteins. For this patient they prescribed a sliding scale insulin therapy to help control blood
glucose levels.
Nutrition Care Form
You were just assigned to review and re-evaluate this patient’s current nutrition support
intervention. You determine the patient is now tolerating the TF. His metabolic cart
measurement was repeated and his current REE is 2557kcal. The physician wants to
discontinue the TPN and feed via TF only. Make new TF recommendations to meet his
nutritional needs. Use the nutrition care form bellow and include your: nutrition assessment,
diagnosis, intervention (including TF recommendations), monitoring and evaluation of your
patient. (10 points – Nutrition Care Form)
Pivot 1.5 provides:
1.5kcal/mL
94g Protein/L
134g Carbohydrate/L
67g Fat/L
772ml Water/L
Nutrition Care Form (10pts)
Age: _29__ Gender: ___Male Height: ___70 in_ Weight: _109 kg______
Medical Diagnosis: _GSW to abdomen_________ Consult: _MD consult for Tube Feeding_
ASSESSMENT
Weight History: 6.3 kg increase in one week Ideal Weight:75.45 kg % Ideal Weight: _144%
Activity Level: __sedentary______ Medications: __Propofol @ 35 mL/hr +924 kcal______
Past History: __tobacco user_______________________________________________
Lab Values (Date):_4/1 Sodium 140; BUN 25; creatinine 1.6; Glucose 140; Magnesium 1.5;
Protein 5.1; Albumin 1.9; Prealbumin 5.0; C-reactive protein 220; Osmolarity 296.7; Alkaline
phosphatase (U/L) 540;
Current Diet Order: _NPO,TPN_ Education Needs: _N/A
Energy Needs: __2557 kcal Protein Needs: _131-164 g Fluid Needs: __2557 ml_
Energy Intake: __3888 kcal_ Protein Intake: __194g Fluid Intake:
NUTRITION DIAGNOSIS:
Problem___Less than optimal enteral nutrition composition or modality (NI 2.5)_______
Related To GI needing more stimulation due to GSW/ open abdomen w/subsequent surgery
As Evidence by___lack of bowel sounds, no stool output, and continued wound VAC for
open abdomen and patient tolerating trickle feed @ 5mL/hr_________________
NUTRITION INTERVENTION: __Enteral formula/solution calculation (ND 2.1.1)________
Goal: Begin Pivot 1.5 at a rate of 25 mL/ Hr for 24 Hrs. working as tolerated to a goal rate
of 71mL/Hr with 1242 in additional flushes of water to provide 160 g protein, 2556 kcal
which is 99.96% of his kcal, and 2.557L of water in a 24 hour period.

5. NUTRITION MONITORING: _Enteral Nutrition intake FH. 1.3.1.1
Goal: Enteral nutrition will be monitored to verify tolerance and sufficiency of nutrient as well
as normal intake/output, bowel function, electrolytes, BUN, creatinine, magnesium,
phosphorus, calcium, weight, and hydration status will be monitored daily.
RD Signature: _Laurie Hill, Carole Matadamas, Michael Leclerc (students) Date: 2/24/2015
References
Nelms, M., Sucher, K.P., Lacey, K. & Roth, S.L. (2011). Nutrition therapy &
pathophysiology (2nd ed.) Belmont, CA: Wadsworth, Cengage Learning