- What is the Glasgow Coma Scale (GCS)?
The Glascow Coma Scale is a scoring system used to assign a level of consciousness of a person after brain injury, and is used to assess severity on a scale of 3 to 15. GCS is the most commonly used scale and involves measure of eye opening, verbal response, and motor response. The overall score is the sum of the three categories but all can be evaluated individually as well.
Source(s): http://www.unc.edu/~rowlett/units/scales/glasgow.htm
- What was Chelsea’s initial GCS score? Is anything in the initial physical assessment consistent with this score? Explain.
Chelsea’s initial score was 10 E4V2M4 broken down into an eye opening response score of 4, a verbal response score of 2, and a motor response score of 4. Initially when admitted, it was stated that she had no verbal response but withdrew and moaned when touched. This means that she is somewhat responsive in her comatose state. A score of 3 is very unconscious while a score of 15 is extreme awareness of surroundings while still in a coma. This score of 10 seems consistent with what the actions described.
- Define the following terms found in the admitting history and physical:
- Intensivist: A physician who specializes in the care of critically ill patients (usually in the Intensive Care Unit)
- L-sided hemiparesis: general weakness on the left side of the body
Source(s): http://www.medterms.com
- Read the CT scan and 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.
- What causes edema and bleeding in a traumatic brain injury?
Brain injury occurs as a result of a blow or jolt of the head in which the brain is smashed into the skull wall. The edema is a build-up of water in the spaces around the brain or blood-brain barrier and occurs as the brain tissue swells. This is a natural response to trauma but excess edema can prevent fluids from leaving the brain.
- What general functions occur in the frontal lobe? How might Chelsea’s injury affect her in the long term?
The frontal lobe is responsible for motor functions, memory, problem solving and judgment, planning, reasoning, impulse, and social behavior. Depending on how the severity of the injury Chelsea may suffer from memory loss, impaired motor functions, and personality / emotional alterations.
Source(s): http://www.neuroskills.com/brain-injury/frontal-lobes.php
- What factors place the patient with traumatic brain injury at nutritional risk?
Chelsea is at increased nutritional risk as traumatic brain injuries can cause physical, cognitive, and sensory issues that can result in difficulty swallowing (dysphagia) and cognitive impairment that affects ability to concentrate on food consumption. She is currently unable to feed herself but also she is at nutritional risk because of possible impaired organ function, alterations in vitamin and mineral absorption, possible drug/nutrient interactions, and fluid and electrolyte imbalances.
- Chelsea’s 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.
The most appropriate method to evaluate her height and weight are to use the CDC growth charts that look at stature-for-age and weight-for-age charts for children age 2 to 20. As a 9 year old, Chelsea falls in the 35th percentile for weight and the 49th percentile for height.
- What method should you use to determine Chelsea’s energy and protein requirements? After specifying your method determine her energy and protein needs.
REE (for females age 3-9) = 22.5 x W(kg) + 499
= 22.5 (27.7kg) + 499
= 1122kcal x (stress factor) 1.7
= 1,900 – 2,000 kcal/day
Protein = 2,000kcal/day x .3 (30%) = 600kcal / 4 g/kcal = 150g PRO
- Chelsea was to receive a goal rate of Nutren Jr with fiber @ 85 cc/hour. How much energy and protein would this provide? Show your calculations. Does it meet her needs?
Nutren Jr = 1.0kcal/mL
85 mL x 24 hours = 2040kcal/day
Protein = 12% of kcal from Nutren Jr
= .12 x 2040 = 245kcal / 4 = 61 grams PRO
Although calorie needs are being met, protein needs are not being met.
- Using the patient care summary sheet, answer the following:
- What was the total volume of feeding she received on June 5?
Chelsea received 1495 TF Formula/Flush.
- What was the nutritional value of her feeding for that day?
62 cc/hour for 24 hours:
Energy: (62mL)(24hrs)(44g)/100mL
= 2,226 kcal
Protein: (62 mL)(24hrs)(12g) / 100mL
= 179g PRO
- What percentage of her needs was met?
2,226 actual intake / 1,950 needed intake x 100 = 114%
- There is a note on the evening shift that the feeding was held for high residual. What does that mean?
This means that there was still a high volume of food or liquid left in Chelsea’s stomach from previous feeding, and therefore Chelsea was not given this particular feeding for fear of pulmonary aspiration. This should be taken into consideration because this is a decrease in caloric and protein intake. It also is essential to find out what is causing the residue to hopefully stop its recurrence.
- What is aspiration? What are the potential consequences?
Aspiration is when food or fluid is inhaled into the bronchi and lungs. This can result in choking, food going down the airway, or pneumonia. If choking occurs without notice, a patient in Chelsea’s condition could die.
- What is the usual procedure for handing a high gastric residual? How do you think Chelsea’s situation was handled?
Gastric residual is checked every 4/6 hours and the RV is adjusted as necessary to prevent aspiration from occurring. In those with high gastric residual, the head is to be propped up and tube placement checks should occur before each bolus or every 8 hours if continuous. Enteral feeding is reduced or stopped if necessary and other measures (perhaps TPN) may be necessary for short term. I think there should have been better communication about Chelsea. It should not just have been a chart note as that can impact her nutrient intake and also it should be closely monitored after the first occurrence.
- What other information would you assess on the daily flow sheet to determine her tolerance of enteral feeding?
Other areas to check would be her lab values, blood pressure, blood glucose, bowel movements and urine/nitrogen output.
- Look at the additional information on the patient care summary sheet. Are there any new factors of concern?
There is a lack of urine output and only one soft BM which means that her body is not responding well to the feedings. Possible dehydration and subsequent constipation are of concern. Also, her weight has dropped since entering and this may mean that she is in need of greater protein/kcals to reduce muscle wasting.
- Evaluate Chelsea’s laboratory data. Note any changes from admission day labs to June 3. Are there any changes of nutritional concern?
Since admission, Chelsea’s glucose and calcium levels have leveled out to normal. However, since she has arrived her Chloride level remains elevated and her creatinine and BUN remain low. Her Albumin levels are especially important to not as they have dropped below normal which means she is not getting the amount of protein her body needs to heal during this crucial time. Kidney function may also be of concern based on these numbers, and it is essential to continue to track any changes in BUN, creatinine, and albumin as she progresses.
- On June 6, a 24-hr urine sample was collected for nitrogen balance. On this day, she received 1650 cc of Nutren Jr. Her total nitrogen output was 14 grams.
- Calculate her nitrogen balance from this information. Show all your calculations.
Nitrogen balance = nitrogen intake – nitrogen losses
= 1650mL/24hrs x 12g/100mL
= -5.75
- How would you assess this information? Explain your response in the context of hyper metabolism.
This number is negative meaning Chelsea’s output is greater than her input, which is indicative of her protein intake. Because protein is the macronutrient that contains nitrogen, this means that her protein levels are too low. Her nitrogen balance should be no less than zero.
- Are there any factors that may affect the accuracy of this test?
Nitrogen can be excreted through the skin and also through respiration which may account for some of the nitrogen loss. Her body is also taking in a lot of the protein and using it for healing so her body will naturally be holding onto more nitrogen than it normally would.
- 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 the results in the context of the metabolic stress response.
Chelsea’s number of -5.75 just means she is having a metabolic response and this categorizes her as being in a mild hypermatabolic state, or level 1 stress category. The formula should not need changing for the sake of nitrogen but rather protein. Right now, this just need to be closely monitored but if her hypermetabolic state continues to increase and her nitrogen balance decreases further, a higher protein formula should be administered.
- 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 Chelsea’s rehabilitation.
All members of this team are essential in Chelsea’s recovery. Occupational therapists treat patients with injuries, illnesses, or disabilities by helping patients develop or recover skills needed for daily life. In Chelsea’s case, the occupational therapist will focus on regaining the intellectual ability that existed before the accident – feeding herself, writing, drawing. Speech therapists focus on language, speech, and all aspects of voice. For Chelsea this would include perhaps swallowing, chewing, mouthing words, and regaining speech. Physical therapists focus on building muscular strength to perform daily activities. Right now for Chelsea the goal is to prevent muscle wasting and depending on her progress, the physical therapist will eventually help Chelsea regain the ability to walk, play, and even run.
- The speech pathologist saw Chelsea for a swallowing evaluation on hospital day 10.
- What is video fluoroscopy?
Video fluoroscopy is an x-ray evaluation of swallowing function. X-rays are taken of the mouth/throat/esophagus while foods and liquids of different consistencies and textures are swallowed – these foods/liquids are mixed with barium to allow the x-ray image to be taken.
- What factors were noted that support the need for enteral feeding at this time?
It was noted that Chelsea had choked several times on ice chips, and showed signs of fatigue / decreased cooperation after a few swallows. As a result, her PO feeding was inhibited and her energy intake decreased.
- As Chelsea’s recovery proceeds, she begins a PO mechanical soft diet.
- Calculate her intake and average for these two days of calorie counts.
Chelsea took in about 700 kcals on the first day and about 1000 kcals on the second day. This is extremely low for someone in Chelsea’s condition with her energy needs. This is less than 50% of her EER even with a reduced activity/healing factor.
- What recommendations would you make regarding her enteral feeding?
I would recommend that Chelsea consume at least double the number of calories she is currently consuming, and increase protein intake. Her enteral feeding should contain at least 1,000kcals and to ensure adequate protein (as much of the foods she is consuming is not high in protein, her enteral supplement should be a high protein one.
Source(s): fitday.com for calories
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