Patrick Burrows

Prof. Matuszak
KNH 413
4/24/2016
Case Study #4
1. What is the Glasgow Coma Scale (GCS)?

The Glasgow Coma Scale is used to evaluate and rank the severity of a
traumatic brain injury. The scale uses eye opening response, ranked 14, verbal response, ranked 1-5, and motor response, ranked 1-6. The
lowest score one can receive is a 3 and the highest is a 15. A severe
injury is a score of 8 or less, a moderate injury is a score of 9-12, and a
mild injury is a score of 13-15 (623).

2. What was Chelseas initial GCS score? Is anything in the initial

physical assessment consistent with this score? Explain.

Her initial score was 10, eye- 4, verbal-2, and motor- 4. Chelsea is
exhibiting left side hemiparesis and is not responding verbally. When
she is touched she withdraws and moans. These findings correlate
within each of their respected categories to the score that she received
(623).

3. Define the following terms found in the admitting history and

physical:

a. Intensivist- a physician who specializes in the care and

treatment of patients in intensive care (Intensivist)
b. L-sided hemiparesis- Hemiparesis is weakness affecting one
side of the body. One can still move that side of the body but
they will have a reduced amount of muscle strength
(Hemiparesis)

4. Read the CT scan and the MRI report. The CT scan report was
very general, noting density in the frontal lobe. The MRI
indicated more localized areas of edema and blood in the
frontal lobe. It also discusses a shearing injury.
a. What causes edema and bleeding in a traumatic brain
injury?

Brain injuries are broken down into two different categories,

primary and secondary. The primary brain injury is from the
initial impact of the brain hitting the inside of the skull, leading to
lacerations and crushing brain tissue. The secondary injury
occurs after the primary injury and it includes cerebral edema,

hemorrhage, hematoma, and infection. The edema results from

the protective barriers being broken in the primary injury or over
pressurized in the secondary (622).

b. What general functions occur in the frontal lobe? How

might Chelseas injury affect her in the long term?

The frontal lobe of the brain is responsible for movement,

sensory perception, voluntary control of movement, language,
personality traits, and sophisticated mental events. If the injury
has any lasting impact on this region she may be slow to respond
and have various other difficulties in learning and communication
in her future (601).

5. What factors place the patient with traumatic brain injury at

nutritional risk?

A traumatic brain injury causes an inflammatory response in the body.

This response results in hypermetabolism, hyperglycemia, insulin

resistance, increased gluconeogenesis, lipolysis, and protein wasting

(623). These factors place the patient into an at nutritional risk
category.

6. Chelseas height is 132 cm, and her weight on admission is

27.7 kg. At 9 years of age, what is the most appropriate
method to evaluate her height and weight? Assess her height
and weight.

At her age the most appropriate way to assess her height and weight
would be to assess her BMI and then compare it to the percentile score
in the CDC growth chart. Her BMI is 27.7/1.322= 15.89. Using this in
the growth char it is found that she is within the 20th percentile (Growth
Charts). She is light for her age but it is not within an area of nutritional
concern.

7. What method should you use to determine Chelseas energy

and protein requirements? After specifying your method,
determine her energy and protein needs.

In order to calculate Chelseas energy needs the Mifflin-St. Jeor

Equation may be used (65).

REE= 10(27.7)+6(132)-5(9)-161= 863(1.4)=1208=1200-1300

calories/day

The current RDA for protein is 1-1.5g/day (66). Chelsea would need
approximately 27-46g of protein per day in order to meet this
recommendation.

8. Chelsea was to receive a goal rate of Nutren Jr at 85 cc/hour.

How much energy and protein would this provide? Show your
calculations. Does it meet her needs?

85ml/hr x 1 kcal/ml= 85 kcal/hr x 24 hr= 2040 kcal/day

Protein= 61g/day
If she is given 85cc/hr of Nutren Jr. her energy and protein needs would
be satisfied (Nutrition Panel).

9. Using the patient care summary sheet, answer the following:

a. What was the total volume of feeding she received on
June 5?

On June 5th Chelsea received 1580ml over the course of her

feedings.

b. What was the nutritional value of her feeding for that

day? Calculate the total energy and protein.

Nutren Jr. contains 1kcal/ml so she was provided with 1580

calories. She was provided with 47g or protein.

c. What percentage of her needs was met?

1580/1300 calories x 100= 121% of her daily caloric needs were

met.
47/46g protein x 100= 102% of her daily protein needs were
met.

d. There is a note on the evening shift that the feeding was

held for high residual. What does that mean?

Held for high residual means that the tube feeding was held off
due to a high residual of fluid still in the stomach. Retained fluid
in the stomach may be a sign of intolerance to the tube feeding
(Fessler).

e. What is aspiration? What are the potential consequences?

Aspiration is the inspiration of foreign matter into the lung (89).

The possible consequences of aspiration are drowning, hypoxia,
or aspiration pneumonia.

f. What is the usual procedure for handling a high gastric

residual? How do you think Chelseas situation was
handled?

Patients are checked for GRV every 4 hours if they are critically ill
and every 6-8 hours if they are not. If someone has high gastric
residual they may be given a narcotic antagonist, such as
Narcan, to combat bowel motility. They are also placed so that
their upper body is between a 45 and 90-degree angle in an
effort to reduce aspiration risk (Fessler). Her situation was
handled by reducing her amount of feedings in an effort to allow
the body to digest what has already been given to it.

g. What other information would you assess on the daily

flow sheet to determine her tolerance to the enteral
feeding?

In order to assess her tolerance I would look for any notes about
abdominal tenderness, how many bowel movements she had, as
well as how much she voided over the course of the day.

h. Look at the additional information on the patient care

summary sheet. Are there any factors of concern?
Explain.

I find it concerning that they did not check her blood glucose
levels since she is a candidate for insulin resistance and they
need to make sure that she is being adequately nourished.

10.

Evaluate Chelseas laboratory data. Note any changes

from admission day labs on June 3. Are any changes of

nutritional concern? Explain.

Over the course of her hospital stay Chelseas albumin level decreased
to 3.3. This is of nutritional concern because it shows that she is
protein deficient in a time in her life where she needs additional protein
to help her heal.

11.

On June 6, a 24-hour urine sample was collected for

nitrogen balance. On this day, she received 1650 cc of Nutren

Jr. Her total nitrogen output was 14 grams.
a. Calculate her nitrogen balance from this information.
Show all your calculations.

(1650 cal x .12)/4= 49g PRO

(49PRO/6.25)- 14g urea nitrogen- 4= -10
(pg. 58)

b. How would you assess this information? Explain your

response in the context of her hypermetabolism.

When someone has a TBI they are at risk for hypermetabolism,

which results in protein catabolism (623). This is evidenced by
her negative nitrogen balance and increased output.

c. Are there any factors that may affect the accuracy of this
test?

There could have been some type of error over the course of the
day with the urine collection, such as human error. This

calculation also does not take into account any renal

insufficiency (58).

d. The intern taking care of Chelsea pages you when he

reads your note regarding negative nitrogen balance. He
asks whether he should change the enteral formula to
one higher in nitrogen. Explain the results in context of
the metabolic stress response.

Research indicates that nitrogen balance is not usually achieved

until the third week (623). Her formula should not be changed
because it is allowing for her to receive the proper amounts of
protein and calories.

12.

Chelsea has worked with occupational therapy, speech

therapy, and physical therapy. Summarize the training that

each of these professionals receives and what their role might
be for Chelseas rehabilitation.

Occupational therapists must obtain a masters degree to obtain a job

in their field. An occupational therapist will be working with Chelsea to
regain and increase her mobility and motor function in household and
work related tasks. Speech therapists must complete a masters degree

and a clinical fellowship. A speech pathologist will be assisting Chelsea

in regaining any deficit that she may have received in swallowing and
speaking due to her brain injury. Physical therapists must obtain a
masters degree to obtain a job in their field. A physical therapist will be
working with Chelsea to regain and increase her mobility and motor
function (8).

13.

The speech pathologist saw Chelsea for a swallowing

evaluation on hospital day 10.

a. What is a video fluoroscopy?

A video fluoroscopy is a test that allows a speech pathologist see

if fod is going into your airway instead of your stomach, which
parts of your mouth and throat are working, and which foods are
safest for you to swallow. This test is done using radiologic
technology (Videofluoroscopic Swallowing Study).

b. What factors were noted that support the need for

enteral feeding at this time?

Chelsea choked after 5-7 ice chips and exhibited fatigue after a
few swallows. This is not adequate to move her to an oral diet.

14.

a. a. Calculate her intake and average for these two days of

calorie counts.

According to SuperTracker Chelseas intake on 10/14 was

approximately 700 calories and on 10/15 her approximate intake
was 1100 calories.

b. What recommendations would you make regarding her

enteral feeding?

I would recommend that she continues to progress in the oral

feedings until she is able to bring in enough calories to meet her
needs. While she is waiting to progress her diet can be
supplemented with the enteral feedings.

References
Fessler, T. A. (n.d.). Gastric Residuals - Understand Their Significance to
Optimize Care. Retrieved April 25, 2016, from
http://www.todaysdietitian.com/newarchives/060210p8.shtml
Growth Charts. (2009). Retrieved April 25, 2016, from
http://www.cdc.gov/growthcharts/clinical_charts.htm
Hemiparesis. (2014). Retrieved April 25, 2016, from
http://www.stroke.org/we-can-help/survivors/stroke-recovery/poststroke-conditions/physical/hemiparesis
Intensivist. (n.d.). Retrieved April 25, 2016, from http://www.merriamwebster.com/medical/intensivist

Nutrition Panel. (n.d.). Retrieved April 25, 2016, from http://www.nestlenutrition.com/Products/Nutrition_Panel.aspx?ProductId=c7040a9f-6f3a4b7b-9eca-8ba70752a453

Videofluoroscopic Swallowing Study. (n.d.). Retrieved April 27, 2016, from
http://www.asha.org/public/speech/swallowing/VideofluoroscopicSwallowing-Study/