Case Study Questions

I. Understanding the disease and pathophysiology

1. Define traumatic brain injury. What is the Glasgow coma scale? What was

Chelsea’s initial GCS score? What findings from the physical exam are

consistent with this score?

Traumatic brain injury occurs when an external mechanical force causes brain

dysfunction. Traumatic brain injury usually results from a violent blow or jolt to

the head or body. An object penetrating the skull, such as a bullet or shattered

piece of skull, also can cause traumatic brain injury. Mild traumatic brain injury

may cause temporary dysfunction of brain cells. More serious traumatic brain

injury can result in bruising, torn tissues, bleeding and other physical damage to

the brain that can result in long-term complications or death. Car crashes, falls,

sports, and assaults can cause brain trauma. The Glasgow coma scale is the most

common scoring system used to describe the level of consciousness in a person

following a traumatic brain injury. Basically, it is used to help gauge the severity

of an acute brain injury. The GCS is a reliable and objective way of recording the

initial and subsequent level of consciousness in a person after a brain injury. It is

used by trained staff at the site of an injury like a car crash or sports injury and in

the emergency department and intensive care unit. The GCS measures the

following fuctions:

Eye Opening (E)

4= spontaneous

3= to voice

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2= to pain

1= none

Verbal Response (V)

5= normal conversation

4= disoriented conversation

3= words, but not coherent

2= no words, only sounds

1= none

Motor Response (M)

6= normal

5= localized to pain

4= withdraws to pain

3= decorticate posture (an abnormal posture that can include rigidity, clenched

fists, legs held straight out, and arms bent inward toward the body with the wrists

and fingers bend and held on the chest)

2= decerebrate (an abnormal posture that can include rigidity, arms and legs held

straight out, toes pointed downward, head and neck arched backwards)

1= none

Every brain injury is different, but generally, brain injury is classified as serve,

moderate, and mild. Serve is a score of 3-8 and you cannot score lower than

three. Moderate is a score of 9-12 and mild is a score of 13-15. The GCS is

usually not used with younger children, especially those too young to have

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reliable language skills. The pediatric Glasgow Coma scare has a modified scale

as follows:

Eye opening (E)

4= spontaneous

3= to voice

2= to pain

1= none

Verbal Response (V)

5= smiles, oriented to sounds, follows objects, interacts

4= cries but consolable, inappropriate interactions

3= inconsistently inconsolable, moaning

2= inconsolable, agitated

1= none

Motor Response (M)

6= moves spontaneously or purposefully

5= withdraws from touch

4= withdraws to pain

3= decorticate posture (an abnormal posture that can include rigidity, clenched

firsts, legs held straight out, and arms bent inward toward the body with the wrists

and fingers bend and held on the chest)

2= decerebrate (an abnormal posture that can include rigidity, arms and legs held

straight out, toes pointed downward, head and neck arched backwards)

1= none

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Pediatric brain injuries are classified by severity using the same scoring levels as

adults. (Mayo Clinic, Brainline)

Chelsea’s initial GCS score was a 10. This is consistent with a score of

ten because of the symptoms of obtundation and L-sided hemiparesis, no verbal

response, withdrawal, and moaning when touched.

2. Read the radiology reports and the MD progress note dated 5/3. What

causes edema and bleeding after a traumatic brain injury? What general

functions occur in the frontal lobe? How might Chelsea’s injury affect her in

the long term?

Brain edema leading to an expansion of brain volume has a crucial impact

on morbidity and mortality following traumatic brain injury as it increases

pressure, impairs cerebral perfusion and oxygenation, and contributes to

additional ischemic injuries. Bleeding in and around the brain, swelling, and

blood clots can disrupt the oxygen supply to the brain and cause wider damage.

Edema is the body’s response to many types of injury. Swelling can occur in

specific locations or throughout the brain. Swelling can block other fluids from

leaving the brain such as blood making the swelling even worse.

The frontal lobe is the brains largest lobe, so obviously it is very

important. The frontal lobe is responsible for reasoning, planning, parts of

speech, movement, emotions, personality, and problem solving. It consists of a

right and left lobe or hemispheres. The left frontal lobe deals with language

abilities while the right frontal lobe is generally concerned with non-verbal

aspects of communication, such as awareness of emotions in one’s facial

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expressions. The left frontal lobe damage will affect language, verbal skills and

positive emotions, while right frontal damage will affect non-verbal

communication and negative emotions.

If the frontal lobe is damaged it could negatively effect Chelsea’s life in

the future many different ways. The degree of dysfunction after the brain trauma

has been resolved depends on the abilities of the individual before the TBI, was

well as the extent, location, and nature of the damage. It may affect aspects of

behavior, mood, and personality, during recovery, the family will have to adapt to

what was previously basic human behavior, such as the relationship with oneself

and others. Behavioral problems of people with frontal lobe damage complicate

recovery. She could experience mood swings, depression, hyperactivity to

aggression, and may run away. Intolerance for frustration and easily provoked

aggression are typical. Brain injuries do not heal like broken bones and even with

today’s technology it can be hard to predict if a person will ever fully recover.

(Mayo Clinic, PedMed, Brain Injury Institute)

3. Describe the inflammatory response that occurs in metabolic stress. Explain the

effects of this response on carbohydrate, protein, and lipid metabolism.

Metabolic stress is the hypermetabolic, catabolic response to acute injury or

disease. Diagnoses that may lead to metabolic stress include trauma as seen in a

gunshot would or motor vehicle accident; closed head injury, etc. Many

metabolic abnormalities are observed in the stress response. Some of these

abnormalities include increased levels of glucagon, cortisol, epinephrine,

norepinephrine; hyperglycemia and insulin resistance; increased basal metabolic

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rate; increased rate of gluconeogenesis; catabolism of skeletal muscle; increased

urinary nitrogen excretion, negative nitrogen balance; increased synthesis of

positive acute-phase proteins; decreased synthesis of negative acute-phase

proteins, albumin, prealbumin. There are three phases: the ebb phase, the flow

phase, and finally the recovery or resolution phase. The ebb phase encompasses

the immediate period (2-48 hours) after injury characterized by shock resulting in

hypovolemia and decreased oxygen availably to tissue. The decrease in blood

volume results in decreased cardiac output and urinary output. As the patient

stabilizes hemodynamically, the acute period of the flow phase begins. This is

where the classic symptoms described above can be seen. The recovery phase

indicates a resolution of the stress with a return to anabolism and normal

metabolic rate. (Nelms 683-684)

During nutrition therapy for metabolic stress there is a delicate balance

between prevention of protein energy malnutrition and prevention of the possible

complications of nutrition support. The amino acid glutamine is recommended

for all trauma patients. Even though glutamine is a nonesstial amino acid, the

body’s synthesis rate cannot meet the increased needs during the stress of critical

injury.

II. Understanding the Nutrition Therapy

4. Based on evidence-based guidelines, what is the proposed role of nutrition

support in Chelsea’s medical care?

The TBI or concurrent injuries may cause damage to the digestion process. Total

parenteral nutritional should be started within 24-48 hours if the gut is not

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working. Nutrition therapies should include exact fluid resuscitation goals

specific for TBI and strict electrolyte monitoring to avoid extreme fluid,

electrolyte, or glucose shirts that could be detrimental to the patients. While the

critical care patients can often tolerate small bowel feeding, the long-term

rehabilitation patient should transition to and evaluated in patients receiving

enteral nutrition. Monitoring for dysphagia is critical to avoid the costly negative

aspects associated with aspiration and to capitalize on quality of life and

appropriate oral nutrition. Special attention should be paid to the food drug

interactions to insure that the patient does not have chronic diarrhea.

Emphasizing the priority of early nutrition support within a multi-disciplinary

team may be the critical key for successful provision and tolerance of nutrition

support. (Pub Med)

5. Are there specific nutrients that are recommended to support the care of an

individual with a TBI?

A healthy diet during the recovery from a brain injury is highly beneficial. When

someone sustains a brain injury, it is necessary to eat enough nutritional calories

to help the brain function efficiently. It is highly recommended that fresh

vegetables, fruits, fish, meats, and grains are superior to processed foods and build

the immune system. In addition, there are a few suggested supplements may help

complement and enhance your nutritional intake. A multivitamin can supply the

basic vitamins and supplement that your diet may be lacking. Omega-3 fatty

acids counteract free radicals that cause oxidative damage to brain cells and may

help improve nerve signal transmission at synapses. Probiotics are a beneficial

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bacteria that helps maintain a healthy intestine and aids in digestion. Antioxidants

which include vitamins C, E, and beta carotene counteract oxidative damage

caused by certain foods, and stress caused by brain injury. Brain Vitale is a

product that combines two beneficial brain nutrients phosphatidyl serine and

acetyle carnitine, which help repair neurons. Phosphatidyl serine aids in the

proper release and reception of neurotransmitters in the brain help with memory.

Acetyle L-carnitine plays a key role in fatty acid oxidation and is used to improve

memory. Coenzyme Q10 is a natural antioxidant that is necessary for the basic

functioning of cells. B vitamins boost metabolism and effect brain and nervous

system functioning. And lastly, glycerphosphocholine helps to sharpen alertness,

reasoning, information processing, and other types of mental performance.

(brainline)

6. Chelsea is a 8 year old. What specific concerns should the RD have for

planning the nutrition care of a pediatric patient?

When planning a nutrition plan for an 8 year old female, especially with a brain

injury, things can get complicated. This is an important growing period for a

child and they can be malnourished much faster than an adult. Since she

sustained a traumatic brain injury her ability to swallow and feed herself can be

negativity affected. The main concern for the dietician is to make sure that

Chelsea is consuming an adequate diet. Another goal of the dietician is to get

Chelsea to regular oral intake as soon as possible.

III. Nutrition Assessment

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7. Assess Chelsea’s admitting height and weight. Provide the rationale for the

reference standards that you have used.

When Chelsea was admitted she weighed 61 pounds or 27.7kg and was 52 inches

tall. These standards are within the normal range. She was 50th percentile for

weight for her age and 75th percentile in height for her age.

8. Determine Chelsea’s admission requirements for the following:

a. Fluid

Daily maintenance fluid requirement for a child of greater than 20 kg is 1,500ml with an

additional 20ml/kg for every kilogram over 20 kilograms.

1,500+ (20 x 7)= 1,640ml

b. Calories

EER= 88.5-61.9 x age + PA x (10 x weight kg) + (934 x heigh meters)+ 20= 88.5-61.9 x 8 + 1.2 x (10 x 27.7kg) + (934x 1.32) + 20= 2,100 kcals RDA- 70kcal/kg, 27.7 x (69kcal-79kcal)= about 1,900-2,200kcalsWHO- 22.5 x wt + 499Apply stress factor of 1.2 for active and 1.3 for stress1,122kcal x 1.2 x 1.3= about 1,700-1,800kcals

c. Protein

1g/kg= 27.7grams

27.2 gram/ 4kcals= 109kcals of protein

Chelsea’s protein was increased to 1.5g/kg eventually to help her recover

more quickly from the traumatic brain injury.

1.5g/kg= 42grams

40.5g/ 4kcals= 162kcals of protein

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When calculating Chelsea’s calories with the pediasure 1.5 we came to the

conclusion that her intake of protein was high and that we could go as high

as 2g/kg, which is about 55 grams.

55grams

d. Vitamins

A= 700ug

D= 10ug

E= 7mg

K= 30ug

Ascorbic acid (mg)= 45

Thiamine (mg)= 1.0

Riboflavin (mg)= 1.2

Niacin (mg)= 13

B6(mg)= 1.4

B12 (ug)= 1.4

Folic acid (ug)= 100

Pantothenic acid (ug)= none

Biotin (ug)= 150-300

e. Minerals

Calcium= 800mg

Phosphorus= 800mg

Magnesium= 170mg

Iron= 10mg

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Zinc= 10mg

Iodine= 120ug

Selenium= 30ug

f. Electrolytes

Sodium= 2-4 mEq/kg

Potassium= 2-3 mEq/kg

Chloride= 2-3 mEq/kg

Magnesium= 0.25-0.5 mEq/kg

Calcium Gluconate= 100-500mg/kg

Phosphorus= 1-2mmol/kg

9. Chelsea was to receive Pediasure 1.5 at a goal rate of 57 cc/hr. How much energy

and protein does this provide? Show your calculations. Does it meet her needs

that you determined in question #8?

1.5 kcal/cc x 57 cc/hr x 24 hr/day 1cc= 2,100 kcals

2,100 kcals/ 1.5= 1,400cc of pedialite 1.5

1.4L x 59g= 83g of protein

These calculations show that her needs were met. In the instance of protein her

needs were 150% met and with calories they were 100% met. She consumed more than

she was recommended to for protein, but in tube feeding getting the required amount of

calories is the most important thing.

83g consumed / 55g required= 150%

10. Using the intake/output record for 5/2, answer the following:

a. What was the total volume of her feeding for 5/2?

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The total volume of Chelsea’s tube feeding was 1,176 mL on 5/2. 1,026 mL of

this volume came from Pediasure 1.5, and 150 mL came from the tube feeding

water flush.

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

total energy and protein.

One serving of Pediasure 1.5 is 8 fluid ounces or 273 mL. This contains 350kcals,

and 14 grams of protein. To calculate the total energy and total protein the

equations below are used:

350 kcal/273 mL=1.28 kcal/mLx1,026mL=1,315 kcals

14g protein/273 mL=0.05 g/mLx1,026=~53 grams protein

c. What percentage of her needs was met? What percentage of her prescribed

feeding did she actually receive? What factors may interfere with the patient

receiving her prescribed nutrition support? What steps can be taken to ensure

that the patient is receiving her prescribed enteral feeding in full?

Chelsea only got about ~60% of her needs met since she received about ~1,300

calories from her Pediasure 1.5. She needs about ~2,100 kcal per day. She was

prescribed feedings of 57 cc per hour of Pediasure 1.5 so she should have

received at least ~1,300 kcals. Her intake showed that she only got 1,026 kcals,

which is only about 75% of the amount that she was prescribed. Some factors that

could interfere with Chelsea getting her prescribed nutrition support could be

improper use of feeding tubes and feeding intolerance that causes vomiting,

diarrhea, nausea etc. To ensure that Chelsea is receiving her prescribed enteral

feeding in full a continuous feeding should be administered at a steady rate

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throughout the day. If high gastric residuals are present, tube feeding should be

stopped.

PediaSure® 1.5 Cal. (n.d.). Retrieved October 23, 2014.

Signs That a Feeding Tube Is Working. (2010, September 28). Retrieved October

23, 2014.

11. Assess Chelsea’s laboratory values at admission and on day 11. Please explain

your interpretation of each abnormal lab.

Admission Day: On the day Chelsea was admitted many of her lab values were abnormal.

Her glucose was high, her bilirubin was high, her alkaline phosphatase was high, her

lactate was high, her fibrinogen was high, and her c-reactive protein was high. Her

glucose was high most likely because she just went through a stressful injury, which

triggered her fight-or-flight response. Her bilirubin was high also because of her

traumatic brain injury. Bilirubin is an endogenous antioxidant, and can show up in higher

levels following an accident. Her alkaline phosphatase was high because high alkaline

phosphatase levels are often associated with certain medical conditions. Her lactate levels

were high because this is very common following a TBI since there is great disturbance

in the brain. Her fibrinogen was high likely because she just went through trauma, which

can cause levels to be high. Her c-reactive protein was high also because of her accident.

Day 11: On day 11 Chelsea’s protein was low, her albumin was low, her alkaline

phosphatase was high, her fibrinogen was high, her c-reactive protein was high, and her

hemoglobin and hematocrit were low. Her protein and albumin were low because

proteins are used to synthesize glucose, which can lower protein levels. Her alkaline

phosphatase levels are still high from day 1, and other medical conditions. Her fibrinogen

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were also still high because of the recent trauma she went through, and her c-reactive

protein was also still high because of her accident. Her hemoglobin and hematocrit were

low because of blood loss of anemia.

Result Filters. (n.d.). Retrieved October 23, 2014, from http://www.ncbi.nlm.nih.gov

Stress. (n.d.). Retrieved October 23, 2014, from http://www.diabetes.org

12. What information in the MD progress note (written on day 12) provides data

you can use to plan Chelsea’s nutrition support? Assess Chelsea’s current

nutritional status on day 12 of her admission. Evaluate her current hydration status,

enteral feeding, and any additional information you have available to assess her

current condition.

The MD’s progress note shows that Chelsea has lost weight, which is the main concern

when planning Chelsea’s nutrition support. When Chelsea came in she weighed almost

28 kg, and she now weighs 23 kg, which is a huge weight loss in a 12 day time period.

On day 12 of her admission Chelsea did not get the amount of calories she should have,

which is also evident by her weight loss. Her hydration and enteral feeding status show

that she is getting rid of almost everything she is taking in. It is very important now to

make sure Chelsea is getting enough calories and fluids, and that the tube feeding is

working properly.

13. On 5/2, a 24-hour urine sample was collected for nitrogen balance. Her total

urine urea nitrogen was 12 g.

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a. Using the intake/output information for that day, calculate her nitrogen balance.

How would you assess this information? Explain your response in the context of her

potential hypermetabolism.

Nitrogen Balance=Nitrogen Intake-Nitrogen Lost

Nitrogen Intake=14 g/237 mL x 1,176= ~70 grams

70 grams/6.25=11.2

Nitrogen Balance=11.2-16=-4.8

A negative nitrogen balance is very common for someone who just went through a

serious injury, or someone who is going through a period of fasting. Negative nitrogen

balances can also be used as an evaluation for malnutrition. Hypermetabolism is

characterized by extreme weight loss, and typically occurs after injury to the body.

Elevation of metabolic rate following a brain injury has been reported with estimates of

32-200% above normal values.

Result Filters. (n.d.). Retrieved October 23, 2014, from http://www.ncbi.nlm.nih.g

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

There are many factors that can either make nitrogen balance results positive or negative.

Periods of growth, pregnancy, and tissue repair all can cause a nitrogen balance to be

positive while fevers, burns, wasting diseases, and other injuries can cause nitrogen

balance’s to be negative.

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c. The intern taking care of Chelsea pages you when he reads your note regarding

her negative nitrogen balance. He asks whether he should change the enteral

formula to one higher in nitrogen. Explain your response to him.

I do not think that Chelsea’s enteral formula should be changed to one that is higher in

nitrogen. Negative nitrogen balance’s can be very common in those who have just been

through a serious injury or have a problem with malnutrition or wasting. These values

can also last for a couple weeks. Chelsea has experienced both of these symptoms in

some aspects so changing her formula would likely not make much difference on her

nitrogen balance values.

IV. Nutrition Diagnosis

14. Select two nutrition problems and complete the PES statement for each.

1. Unintended Weight Loss (NC-3.2) related to inability to consume sufficient

energy as evidenced by severe weight loss.

2. Swallowing Difficulty (NC-1.1) related to traumatic brain injury as evidenced

by failed speech/swallowing evaluation.

V. Nutrition Intervention

15. For each PES statements that you have written, establish an ideal goal (based on

the signs and symptoms) and an appropriate intervention (based on the etiology).

For the first PES statement an ideal goal would be to have Chelsea get back to the weight

she was before her injury. To do this it is crucial that her tube feeding is working properly

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to give her the amount of calories she needs a day, and if not her calories should be

adjusted.

For the second PES statement an ideal goal would be to gradually add soft foods to

Chelsea’s diet. If Chelsea no longer has difficulty swallowing, a regular diet can then be

given to her.

16. Write your follow-up nutrition note for 5/3.

Since Chelsea has lost almost 5kg since she was first admitted the main concern is getting

her to gain weight and get enough protein in her diet. It is very important to make sure

Chelsea is eating enough calories each day (around ~2,100), especially since she is on

enteral feeding, which can be difficult to monitor. Chelsea should continue on tube

feeding until she passes the speech/swallowing evaluation, and feels she is able to start

eating soft foods. One she passes the evaluation, Chelsea should try eating thickened

beverages and soft foods that will go down easily. Eventually Chelsea can transition back

to a regular diet.

VI. Nutrition monitoring and Evaluation

17. Chelsea has worked with an occupational therapist, a speech therapist, and a

physical therapist. Summarize the training that each of these professionals received

and describe their expected roles in Chelsea’s rehabilitation.

Occupational Therapist: The first step to becoming an Occupational Therapist is to

receive your Bachelor’s degree. Some common majors chosen include sociology,

psychology, and anthropology. Next you must earn your master’s degree; most degrees

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here include: anatomy, patient care, and assistive technology. Fieldwork is usually done

in nursing homes, rehab centers, and schools. Next you must get your license in your

state. In order to receive your license you must: have graduated from an accredited

occupational therapy program, have completed necessary fieldwork, and passed the

NBCOT exam. You will then receive your Occupational Therapist Registered Credential.

The expected role of an Occupational Therapist in Chelsea’s rehabilitation would be to

assist her in independence of all aspects of her daily life. This would include daily living,

productive activities, leisure activities, and help guide the process of OT. Treatment

sessions usually focus on engaging individuals in meaningful activities to help them in

achieving their goals to reach independence. This will also help Chelsea a lot when she is

transitioning back to her daily school life.

Speech Therapist: The first step to becoming a Speech Therapist is to complete your

bachelor’s degree with coursework in communications and biological sciences. Next you

must receive your Master’s degree from an accredited program usually completed in 2 or

3 years. This provides training through coursework, research, and clinical experiences.

Courses usually include anatomy, physiology, phonetics, linguistics, and phonology.

Students must then complete 25-40 hours of on-site, supervised training to complete their

degree. You must then get your licensure after completing an accredited ASHA.

Additional hours must be completed to maintain your licensure. The expected role of a

Speech Therapist in Chelsea’s rehabilitation would be to help her with getting general

responses to sensory stimulation and teaching family members to interact with her at the

beginning stages of her recovery. Once she becomes more aware the Speech Therapist

must then help her maintain her attention for simple activities, reduce her confusions, and

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help get her oriented with where she is, what happened, what day it is etc. Later on in her

recovery the Speech Therapist will: help her find ways to improve her memory, learn

problem-solving strategies, work on social skills, and improve self-monitoring. Towards

the end of her treatment, the Speech Therapist can help her get back to her school life.

Physical Therapist: In order to become a Physical Therapist you must first get a

bachelor’s degree in a number of area including biology, anatomy, pre-physical therapy

and more. You then need to get a graduate degree. Doctoral programs and master’s

programs are both available. Doctor of Physical Therapy programs train students in the

procedures of diagnosis and treatment. Clinical clerkships in DPT programs place

students in healthcare facilities under the supervision of licensed physical therapists.

Next, most states typically require a passing score on the National Physical Therapy

Examination as part of getting your license. Continuing education must then be done to

retain your license. The role of a Physical Therapist in Chelsea’s rehabilitation will be to

help her in movement to help strengthen her physical abilities. This will help relieve pain

through exercise. They will also help her with motility and recommend devices to help

her move independently.

Education Required to Become a Physical Therapist. (n.d.). Retrieved October 23, 2014.

How To Obtain Your Occupational Therapy Degree. (n.d.). Retrieved October 23, 2014,

from http://www.otplan.com/articles/how-to-obtain-your-occupational-therapy-

degree.aspx

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Speech Therapy Training. (n.d.). Retrieved October 23, 2014, from

http://link.springer.com/chapter/10.1007/978-0-387-37575-5_12 http://education-

portal.com/speech_therapy_training.html

Traumatic Brain Injury (TBI). (n.d.). Retrieved October 23, 2014, from

http://www.asha.org/public/speech/disorders/TBI/

18. The speech pathologist saw Chelsea for a swallowing evaluation. What is FEES?

What factors in the speech pathologist’s report indicate the continued need for

enteral feeding?

FEES stands for Fiberoptic Endoscopic Evaluation of Swallowing, and is a procedure

that allows physicians to assess areas surrounding the voice box and opening of the

esophagus, through the use of a small flexible telescope. The telescope is passed through

the nose after anesthetizing the area to minimize pain or discomfort. One the telescope is

in position, your child is given various foods to eat. The specialist observes and evaluates

the swallowing process. After the procedure the specialist can give you and your child

specific recommendations to improve safety and efficacy of swallowing. It is evident that

Chelsea needs to continue on her enteral feeding because in the report it stated that

Chelsea choked after 5-7 ice chips, and she showed significant signs of fatigue and

decreased cooperation after a few swallows. She later also failed her speech/swallowing

evaluation on day 12.

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Speech-Language Pathology. (n.d.). Retrieved October 23, 2014, from

http://www.cincinnatichildrens.org/service/s/speech/specialty-clinics/fees/

19. As Chelsea’s recovery proceeds, she begins a PO mechanical soft diet. Her

kcalorie counts are as follows:

5/14: oatmeal ¼ c; brown sugar 2 tbsp; whole milk 1 c; 240 cc Carnation Instant

Breakfast (CIB) prepared with 2% milk; mashed potatoes 1 c; gravy 2 tbsp

5/15: Cheerios 1 c; whole milk 1 c; 240 cc CIB prepared with 2% milk; grilled

cheese sandwich (2 slices bread, 1 oz American cheese 1 tsp margarine); Jell-O 1 c;

240 cc CIB prepared with 2% milk.

a. Calculate her daily kcal and protein intakes and the average for these 2 days

of kcalorie counts.

5/14

Food Item Calories (kcal) Protein (grams)

¼ cup oatmeal 75 2.5g

2 tbsp brown sugar 15 0g

1 cup whole milk 150 8g

240 cc Carnation

Instant Breakfast with

2% milk

320 13g

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1 cup Mashed Potatoes ~200 4g

2 tbsp gravy 15 0g

Total ~775 ~28

5/15

1 cup cheerios 100 3g

1 cup whole milk 150 8g

240 cc CIB with 2%

milk

320 13g

2 slices bread ~150 5g

1 oz American cheese 70 5g

1 tsp margarine 35 0g

1 cup jell-o ~80 2g

240 cc CIB with 2%

milk

320 13g

Total ~1,200 ~50

Average kcals Average protein

~990 ~40

b. What recommendations would you make regarding her enteral feeding at

this time?

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At this time I would recommend that Chelsea consume an additional 500-1000

calories a day. What she consumed in the 2 days in the chart above shows that she

was not getting nearly enough calories. I would also recommend that Chelsea gets

more protein in her diet. Since Chelsea is at a great risk of losing more of her

body weight it is crucial that she gets adequate energy for her recovery. I would

then recommend that she transition from enteral feedings to a normal diet with

soft foods that she is able to swallow. I would then gradually add more solid foods

to her diet if she were able to tolerate them.

Sources

Education Required to Become a Physical Therapist. (n.d.). Retrieved October 23, 2014.

How To Obtain Your Occupational Therapy Degree. (n.d.). Retrieved October 23, 2014,

from http://www.otplan.com/articles

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PediaSure® 1.5 Cal. (n.d.). Retrieved October 23, 2014.

Result Filters. (n.d.). Retrieved October 23, 2014, from http://www.ncbi.nlm.nih.gov

Signs That a Feeding Tube Is Working. (2010, September 28). Retrieved October 23,

2014.

Speech-Language Pathology. (n.d.). Retrieved October 23, 2014, from

http://www.cincinnatichildrens.org

Speech Therapy Training. (n.d.). Retrieved October 23, 2014, from

http://link.springer.com/chapter/10

Stress. (n.d.). Retrieved October 23, 2014, from http://www.diabetes.org

Traumatic Brain Injury (TBI). (n.d.). Retrieved October 23, 2014, from http://www.asha.org/public/speech/disorders/TBI/

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Work Cited

Mayo Clinic.

http://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/basics/

definition/con-20029302

Brainline.

http://www.brainline.org/content/2010/10/what-is-the-glasgow-coma-scale.html

Pedmed

http://www.ncbi.nlm.nih.gov/pubmed/15561417

Brain Injury Institute.

http://www.braininjuryinstitute.org/Brain-Injury-Types/Frontal-Lobe-

Damage.html

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Pubmed http://www.ncbi.nlm.nih.gov/pubmed/19033220

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brain-nutritional-tips-to-speed-recovery.html

Pitzer 26