CaseStudy34:ClosedHeadInjury:MetabolicStresswithNutritionSupport

SamBallard
KNH413
4.28.2016

1. WhatistheGlasgowComaScale(GCS)?

TheGlasgowComaScale(GCS)isamethodusedtoevaluateandranktheseverityof
traumaticbraininjuries.
EyeOpeningResponse

Score

Spontaneousopenwithblinkingatbaseline

4points

Toverbalstimuli,command,speech

3points

Topainonly(notappliedtoface)

2points

Noresponse

1point
VerbalResponse

Score

Oriented

5points

Confusedconversation,butabletoanswerquestions

4points

Inappropriatewords

3points

Incomprehensiblespeech

2points

Noresponse

1point
MotorResponse

Score

Obeyscommandsformovement

6points

Purposefulmovementtopainfulstimulus

5points

Withdrawsinresponsetopain

4points

Flexioninresponsetopain(decorticateposturing)

3points

Extensionresponseinresponsetopain(decerebrateposturing)

2points

Noresponse

1point
Categorization

Coma:Noeyeopening,noabilitytofollowcommands,nowordverbalizations(38)

HeadInjuryClassification
SevereHeadInjury=GCSscoreof8orless
ModerateHeadInjury=GCSscoreof912
MildHeadInjury=GCSscoreof1315
(Nelms,Sucher,&Lacey,2014)

2. WhatwasChelseasinitialGCSscore?Isanythingintheinitialphysicalassessment
consistentwiththisscore?Explain.

ChelseasinitialGCSscoreis10(E4,V2,M4).Thismeanssheisclassifiedashavinga
moderateheadinjury.Herinitialphysicalassessmentreportsthatherpupilsare4mm
reactivewithnobattle/racoonsigns,shehasobtundation(alteredlevelofconsciousness)
andLsidedhemiparesis,noverbalresponses,andwithdrawalandmoaningwhentouched.
Herresponsivepupilsearnher4points(E4),herlackofverbalresponse,butmoaningwhen
touchedearnsher2points(V2),andherLsidedhemiparesishasweakened,butnot
inhibitedhermotorresponse,earningher4points(M4).Itcouldalsobearguedthatherlack
ofverbalresponseearnsheronly1point,butevenso,shewouldstillbeconsideredas
havingamoderateheadinjury.

3. Definethefollowingtermsfoundintheadmittinghistoryandphysical:
a. Intensivist:

aboardcertifiedphysician,alsoknownasacriticalcarephysician,who
providesspecialcareforcriticallyillpatientshasadvancedtrainingandexperience
andtakesacomprehensiveapproachtocaringforICUpatients(UMassMemorial
MedicalCenter,2014).

b. Lsidedhemiparesis:

weaknessontheleftsideofthebody,whichcanstillbe
moved,butwithreducedmuscularstrength(NationalStrokeAssociation,2016).

4. ReadtheCTscanandMRIreport.TheCTscanreportwasverygeneral,notingdensityin
thefrontallobe.TheMRIindicatedmorelocalizedareasofedemaandbloodinthefrontal
lobe.Italsodiscussesashearinginjury.
a. Whatcausesedemaandbleedinginatraumaticbraininjury?

Edemaandbleedingareconsideredsecondaryinjuriesinatraumaticbraininjury.
Secondaryinjuriesoccurduetophysiologicalchangesduringtheaftermathofthe
initial,orprimary,injury.Primaryinjuriesarecausedbytheinitialpenetrationor
thrashingofthebrainagainsttheinterioroftheskull,leadingtolacerationsand
crushingofbraintissue(Nelms,Sucher,&Lacey,2014).Secondaryinjuriescan
sometimesbethebodysattemptathealingitself,buttheycanbedangerous.

b. Whatgeneralfunctionsoccurinthefrontallobe?HowmightChelseasinjuryaffect
herinthelongterm?

Thefrontallobeisresponsibleforcomplexthought,planning,emotion,voluntary
movement,andspeech.Chelseasinjurytoherfrontallobemayaffectherinthelong
termbycausingimpairmentsinjudgement,lossofmotivation,andunregulated
moodsandemotionsthatmaycausehertobecomeimpulsive,actrashly,andadopt
riskybehaviors(BrainAndSpinalCord.org,2015).

5. Whatfactorsplacethepatientwithtraumaticbraininjuryatnutritionalrisk?

Traumaticbraininjuriestriggerametabolicandinflammatoryresponsethatresultsin
hypermetabolism,hyperglycemiaandinsulinresistance,increasedgluconeogenesis,
lipolysis,andproteinwastinganditsmagnitudeisproportionaltotheseverityoftheinjury
(Nelms,Sucher,&Lacey,2014).Ifnotsupportednutritionally,thiscancausethemtolose
asmuchas15%ofbodyweightinoneweek.Impairedorpainfulmotororverbalresponses
aswellasdisorientationcanalsoleadtoreducedintakeandnutritionalrisk.

6. Chelseasheightis132cm,andherweightonadmissionis27.7kg.At9yearsofage,what
isthemostappropriatemethodtoevaluateherheightandweight?Assessherheightand
weight.

At9yearsofage,themostappropriatemethodtoevaluateChelseasheightandweightis
byusingastatureforageandweightforagepercentilechart.Usingthe2to20yearold
girlschart,itcanbedeterminedthatChelseafallsinthe50thpercentileforstatureforage
andbetweenthe50thand75thpercentileforweightforage.(CentersforDiseaseControl
andPrevention,2000)

7. WhatmethodshouldyouusetodetermineChelseasenergyandproteinrequirements?
Afterspecifyingyourmethod,determineherenergyandproteinneeds.

MifflinSt.Jeor
[10xwt.(kg)+6.25xht.(cm)5xage(yrs)161]xIF
[10x27.7kg+6.25x132cm5x9161]x1.5
[277+82545161]x1.5
896x1.5*=
1,344kcal/day
*1.5InjuryFactor(IF)=Headinjury

Protein
Wt.(kg)x2.0g/kg
27.7kgx1.5g/kg=
41.55g/day

8. ChelseawastoreceiveagoalrateofNutrenJrwithfiber@85cc/hour.Howmuchenergy
andproteinwouldthisprovide?Showyourcalculations.Doesitmeetherneeds?

Volume
(mL)

Energy
(kcal/mL)

Protein
(g/L)

Carbohydrate
(g/L)

Fat(g/L)

Fiber(g/L)

1,000

1.00

30

110

50

Energy:
1.00kcal/mLx85mL=
85kcal
x16hours=
1,360kcal/day
Protein:
30g/Lx0.085mL=
2.55g
x16hours=
40.8g/day

ProvidingChelseawith85ccofNutrenJr.perhourfor16hours(asnotedinhernutrition
consult)willprovideherwithabout1,360kilocaloriesperdayandabout40.8gramsof
proteinperday.DeliveringthesekilocalorieandproteinamountswillmeetChelseasneeds
ofabout1,344kilocaloriesperdayandabout41.55gramsofproteinperday.

9. Usingthepatientcaresummarysheet,answerthefollowing:
a. WhatwasthetotalvolumeoffeedingshereceivedonJune5?

85cc/hrx18hrs(8@night,8@day,2@evening)=1,530cc+50cc(23rdhr)=
1,580ccNutrenJr.total
and30ccflush

b. Whatwasthenutritionalvalueofherfeedingforthatday?Calculatethetotalenergy
andprotein.

1,580ccx1.00kcal/mL=
1,580kcal
1,580ccx(30g/L/1,000mL/L)=
47.4gprotein

c. Whatpercentageofherneedswasmet?

1,580kcal/1,344kcal=1.175=
118%ofkcal
47.4g/41.55g=1.141=
114%ofprotein

d. Thereisanoteontheeveningshiftthatthatfeedingwasheldforhighresidual.What
doesthatmean?

Gastricresidualisanyfood,liquid,ormaterialfromapreviousfeedingthatisleftin
thestomachatthestartofthenextfeeding(OutreachServicesofIndiana,2009).A
highresidualmeansthattherewasalargeamountofmaterialfromaprevious
feedingleftinChelseasstomachatthestartofthenextfeeding,sofeedingwas
postponed.Highresidualvolumesincreasetheriskforpulmonaryaspiration.

e. Whatisaspiration?Whatarethepotentialconsequences?

Aspirationistheinspirationofforeignmatterintothelungs.Thepotential
consequencesofaspirationincludepneumoniaordeathfromasphyxiation(Nelms,
Sucher,&Lacey,2014).ThelowerthepHofaspiratedmaterials,themoreseverethe
respiratorydistress.

f.

Whatistheusualprocedureforhandlingahighgastricresidual?Howdoyouthink
Chelseassituationwashandled?

Tomonitorforexcessivegastricresidualvolumeinacontinuouslyfedpatient,the
gastricresidualvalueshouldbecheckedevery4to6hours.Feedingsareheldfor1
houriftheresidualvolumeis1.5timesthehourlyrate,thenrecheckedata
predeterminedtime.Iftheresidualvaluecontinuestoexceed1.5timethehourlyrate,
thenthefeedingshouldbeheld,agastrointestinalevaluationshouldbeperformed,
andthephysicianshouldbenotified(OutreachServicesofIndiana,2009).IfChelsea
wasdeterminedtohaveahighresidualvolumeinhour18ofJune5th,itismostlikely
thatherfeedingwasheldforanhour,rechecked,andcontinuedtobehelduntilhour
23whenshewasgiven50ccsofformula.Becauseherfeedwasheldformorethan
anhour,itcanbeassumedthatagastrointestinalevaluationwasperformedanda
physicianwasnotified.

g. Whatotherinformationwouldyouassessonthedailyflowsheettodetermineher
tolerancetotheenteralfeeding?

TodetermineChelseastolerancetotheenteralfeeding,itwouldbeimportanttoalso
assesshervoidvolumeandbowelmovements.Becauseherintakeisregulatedat85
cc/hr,heroutputvolumeactsasthedependentvariable.Voidvolumeandtheamount
andtypeofbowelmovementscanindicatehowwellthefeedingsarebeingabsorbed
andprocessedaswellasfluidstatus.

h. Lookattheadditionalinformationonthepatientcaresummarysheet.Arethereany
factorsofconcern?Explain.

Additionalfactorsofconcernonthepatientcaresummarysheet,inadditionto
Chelseasvoidvolume,bowelmovementsandfeedings,areherpulse,respiration,
andbloodpressure.Thesevaluesseemtohaverisenintheeveningtoborderline
highlevels.Thisriseinvaluesmayindicateanincreasedworkloadoncardiacand
respiratoryorgansfromtheinfluxofnutrientsthatmayneedtobemonitored.

10. EvaluateChelseaslaboratorydata.NoteanychangesfromadmissiondaylabstoJune3.
Areanychangesofnutritionalconcern?

Lab

Normal

Admission(5/24)

Day10(6/3)

Albumin(g/dL)

3.65

3.7

3.3L

Chloride(mmol/L)

98108

110H

113H

Glucose(mg/dL)

70120

189H

115

Creatinine(mg/dL)

0.61.3

0.4L

0.4L

Calcium(mg/dL)

8.710.2

8.5L

9.2

Chelseasalbuminlevelhasdroppedfromadmissiontoday10.Thismaybeduetothe
effectofinflammationonalbuminstatusorinadequateproteinorcaloricintake(Don&
Kaysen,2004).Proteinconsumptionmayneedtobeelevateduntilalbuminlevelsreturnto
normal.Herslightlylowcreatininelevelcouldindicatedecreasedmusclemassandmaybe
anotherindicatorformoreproteinandanyexerciseshewouldbeabletodo.Glucoselevels
werealsoelevatedatadmission,butwereloweredintoanormalrangebyday10.
Acute
illness,surgery,andtraumaraiselevelsofstressmediators,namelystresshormonesand
cytokines,thatinterferewithcarbohydratemetabolismleadingtohyperglycemia
(
Gosmanov&Umpierrez,2013).Chelseascalciumwasslightlylowatadmission,butwas
normalbyday10.Thismayhavebeenduetopoordietaryintakeofcalciumbeforeher
traumaandhernutritiontherapyinthehospitalmayhavecorrectedthis.Lastly,herchloride
levelsareslightlyelevatedatbothadmissionandday10indicatingapossibleelectrolyte
imbalancethatcanbeeasilycorrected.

11. OnJune6,a24hoururinesamplewascollectedfornitrogenbalance.Onthisday,she
received1650ccofNutrenJr.Hertotalnitrogenoutwas14grams.
a. Calculatehernitrogenbalancefromthisinformation.Showallyourcalculations.

N2balance=(dietaryproteinintake/6.25)urineureanitrogen4
1,650ccx(30g/L/1,000mL/L)=49.5gprotein
N2balance=(49.5g/6.25)144
N2balance=7.92144
N2balance=
10.08g

b. Howwouldyouassessthisinformation?Explainyourresponseinthecontextofher
hypermetabolism.

Chelseahasanegativenitrogenbalance.Thismeansthathernitrogenexcretionis
greaterthanhernitrogenintake.Thisindicatescatabolism(breakingdownprotein
moleculesintosmallerunitsthatareusedforenergy)orinadequatenitrogen(protein)
intake(Nelms,Sucher,&Lacey,2014).Herinflammatoryresponsetothetraumashe
sustainedcreateddisturbancesinherproteinmetabolism,resultingin

hypermetabolismandcatabolism.Becausetheseincreasenitrogenexcretionand
nitrogenisfoundinprotein,acuteproteinmalnutritioncanoccur(
Beretta,Rocchetti,&
Braga,2010).

c. Arethereanyfactorsthatmayaffecttheaccuracyofthistest?

Inherenterrorof24hoururinecollection.
Failuretoaccountforrenalimpairment.
Inabilitytomeasurenitrogenlossesfromsomewounds,burns,diarrhea,and
vomiting.
Difficultymeasuringoralproteinintake.
(Nelms,Sucher,&Lacey,2014)

d. TheinterntakingcareofChelseapagesyouwhenhereadsyournoteregardingher
negativenitrogenbalance.Heaskswhetherheshouldchangetheenteralformulato
onehigherinnitrogen.Explaintheresultsinthecontextofthemetabolicstress
response.

TheinflammatoryresponsetothetraumaChelseahassustainedcreated
disturbancesinherproteinmetabolism,resultinginhypermetabolismandcatabolism.
Becausetheseincreasenitrogenexcretionandnitrogenisfoundinprotein,acute
proteinmalnutritioncanoccur(
Beretta,Rocchetti,&Braga,2010).Onceher
inflammatoryresponsesisreduced,herhypermetabolismandprotein/muscle
catabolismshouldsubsideandhernitrogenbalanceshouldimprove.Forthese
reasons,itisnotnecessarytochangeChelseasformulatoonehigherinnitrogenat
thistime,butshehernitrogenshouldbecloselymonitoredthroughoutherrecovery.

12. Chelseahasworkedwithoccupationaltherapy,speechtherapy,andphysicaltherapy.
Summarizethetrainingthateachoftheseprofessionalsreceivesandwhattheirrolemight
beforChelseasrehabilitation.

Occupationaltherapy:
Occupationaltherapistshelppeopleacrossthelifespanparticipate
in

thethingstheywantandneedtodothroughthetherapeuticuseofeverydayactivities
(
TheAmericanOccupationalTherapyAssociation,Inc.,2016).Anoccupationaltherapist
wouldhelpChelsearegaintheuseofherfinemotorskillsandthoseskillssheuses
everyday,suchasfeedingherselforwriting.

Speechtherapy:
Speechlanguagepathologistsworktoimprovehumancommunication
andswallowingdisorders(AmericanSpeechLanguageHearingAssociation,2016).A
speechlanguagepathologistwouldcloselymonitorChelseasswallowingabilityto
determineifandwhenshecantransitionfromenteralfeedingtobymouthfeeding.

Physicaltherapy:
Physicaltherapistsrestoreorimprovemusculoskeletalmobilityand
reducepain,usuallywithoutsurgeryorlongtermuseofprescriptionmedications(American
PhysicalTherapyAssociation,2015).Aphysicaltherapistwouldbeabletohelpregain
strengthinChelseasleftside(Lsidedhemiparesis),improvestrengthandmovementinher
injuredextremities,andeventuallyworktowardsresumingherparticipationingymnastics
andsoftball.

13. ThespeechpathologistsawChelseaforaswallowingevaluationonhospitalday10.(Seep.
395.)
a. Whatisavideofluoroscopy?

Videofluoroscopyisaanevaluationoftheswallowingprocess.Amoving,or
dynamic,xrayshowingswallowsoffoodandliquidisrecordedtodetermineifthereis
aswallowingproblemandwhatitis(GreatOrmondStreetHospitalforChildren,
2014).

b. Whatfactorswerenotedthatsupporttheneedforenteralfeedingatthistime?

Chelseasspeech/swallowevaluationfoundevidenceoftheneedforenteralfeeding
atthistime.Althoughsheacceptedmacaroniandcheesewithappropriatetongue
andchewingskills,shechokedafter57icechipsandshowedsignificantsignsof
fatigueanddecreasedcooperationafterafewswallows.Thisinhibitedherfeedingby
mouth.Choking,fatigue,anddecreasedcooperationareimportantfactorsfor
continuedenteralfeeding.

14. AsChelseasrecoveryproceeds,shebeginsaPOmechanicalsoftdiet.Hercaloriecounts
areasfollows:

(10/14)
Oatmealc
Brownsugar2T
Wholemilk1c
240ccCarnationInstantBreakfast(CIB)preparedwith2%milk(182kcal)
Mashedpotatoes1c
Gravy2T

(10/15)
Cheerios1c
Wholemilk1c
240ccCIBpreparedwith2%milk(182kcal)
Grilledcheesesandwich(2slicesbread,1ozAmericancheese,1tmargarine)
Jello1c
240ccCIBpreparedwith2%milk(182kcal)


a. Calculateherintakeandaverageforthesetwodaysofcaloriecounts.

(10/14)
667kcal
(10/15)
1,039kcal
Averagefor2days
853kcal
(UnitedStatesDepartmentofAgriculture,2016).

b. Whatrecommendationswouldyoumakeregardingherenteralfeeding?

IfChelseaisbeginningtotoleratefoodbymouthbetterandifthespeechlanguage
pathologistapproves,enteralfeedingshouldbereducedwhileoralfeedingis
increased.ItisimportantforChelseatoregainthefinemotorskillsassociatedwith
feedingherself,chewing,andswallowingthroughtheuseofanoraldiet.Enteral
feedingshouldbeusedtosupplementoralintaketomeetnutrientgoalsratherthan
remaintheprimarysourceoffeeding.

References

AmericanPhysicalTherapyAssociation.(2015).
Whoarephysicaltherapists?
Retrievedfrom
http://www.apta.org/AboutPTs/

AmericanSpeechLanguageHearingAssociation.(2016).
Speechlanguagepathologists.
Retrievedfrom
http://www.asha.org/Students/SpeechLanguagePathologists/#careers

Beretta,L.,Rocchetti,S.,&Braga,M.(2010).Whatsnewinemergencies,trauma,andshock?
Nitrogenbalanceincriticalpatientsonenteralnutrition.
JournalofEmergencies,Trauma
andShock
,
3
(2),105108.http://doi.org/10.4103/09742700.62099

BrainAndSpinalCord.org.(2015).
Frontallobebraininjury.
Retrievedfrom
http://www.brainandspinalcord.org/braininjury/frontallobe.html

CentersforDiseaseControlandPrevention.(2000).
2to20years:Girlsstatureforageand
weightforagepercentiles.
Retrievedfrom
http://www.cdc.gov/growthcharts/data/set1clinical/cj41c022.pdf

Don,B.R.&Kaysen,G.(2004).Serumalbumin:Relationshiptoinflammationandnutrition.
SeminarsinDialysis,17
(6),4327.

Gosmanov,A.R.,&Umpierrez,G.E.(2013).Managementofhyperglycemiaduringenteraland
parenteralnutritiontherapy.
CurrentDiabetesReports,
13

(1),155162.
http://doi.org/10.1007/s118920120335y

GreatOrmondStreetHospitalforChildren.(2014).
Videofluoroscopicswallowtest.
Retreived
from
http://www.gosh.nhs.uk/medicalinformation0/proceduresandtreatments/videofluorosco
picswallowtest

NationalStrokeAssociation.(2016).
Hemiparesis.
Retrievedfrom
http://www.stroke.org/wecanhelp/survivors/strokerecovery/poststrokeconditions/physi
cal/hemiparesis

Nelms,M.,Sucher,K.P.,&Lacey,K.(2014).
Nutritiontherapyandpathophysiology.
Boston,
MA:CengageLearning.

OutreachServicesofIndiana.(2009).
Managementofgastricresiduals.
Retrievedfrom
http://www.in.gov/fssa/files/aspiration_prevention_8.pdf

TheAmericanOccupationalTherapyAssociation,Inc.(2016).
Aboutoccupationaltherapy.

Retrievedfrom
http://www.aota.org/aboutoccupationaltherapy.aspx


UMassMemorialMedicalCenter.(2014).
Whatisanintensivist?
Retrievedfrom
http://www.umassmemorialhealthcare.org/umassmemorialmedicalcenter/servicestreat
ments/criticalcare/whatintensivist

UnitedStatesDepartmentofAgriculture.(2016).
Supertracker.
Retrievedfrom
https://www.supertracker.usda.gov/foodtracker.aspx