Case Study Questions

Pitzer 1Case 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 22= to pain 1= none Verbal Response (V)5= normal conversation 4= disoriented conversation 3= words, but not coherent 2= no words, only sounds1= 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 Pitzer 3 reliable language skills. The pediatric Glasgow Coma scare has a modified scale as follows: Eye opening (E)4= spontaneous 3= to voice2= 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 4Pediatric 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 Pitzer 5 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 6 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 Pitzer 7 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 8 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 Pitzer 97. 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. FluidDaily 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. CaloriesEER= 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 1,900-2,200kcals WHO- 22.5 x wt + 499 Apply stress factor of 1.2 for active and 1.3 for stress 1,122kcal x 1.2 x 1.3= about 1,700-1,800kcals c. Protein 1g/kg= 27.7grams27.2 gram/ 4kcals= 109kcals of proteinChelsea’s protein was increased to 1.5g/kg eventually to help her recover more quickly from the traumatic brain injury. 1.5g/kg= 42grams40.5g/ 4kcals= 162kcals of protein 10When 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= 700ugD= 10ugE= 7mgK= 30ugAscorbic acid (mg)= 45Thiamine (mg)= 1.0Riboflavin (mg)= 1.2Niacin (mg)= 13B6(mg)= 1.4B12 (ug)= 1.4Folic acid (ug)= 100Pantothenic acid (ug)= noneBiotin (ug)= 150-300 e. Minerals Calcium= 800mg Phosphorus= 800mg Magnesium= 170mg Iron= 10mg Pitzer 11Zinc= 10mg Iodine= 120ug Selenium= 30ug f. Electrolytes Sodium= 2-4 mEq/kgPotassium= 2-3 mEq/kgChloride= 2-3 mEq/kgMagnesium= 0.25-0.5 mEq/kgCalcium Gluconate= 100-500mg/kgPhosphorus= 1-2mmol/kg9. 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? 12The 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 kcals14g 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 Pitzer 13 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 14 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.govStress. (n.d.). Retrieved October 23, 2014, from http://www.diabetes.org12. 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. Pitzer 15 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 LostNitrogen Intake=14 g/237 mL x 1,176= ~70 grams70 grams/6.25=11.2Nitrogen Balance=11.2-16=-4.8A 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. 16 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 Diagnosis14. 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 Intervention15. 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 Pitzer 17 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 Evaluation17. 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 18 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 Pitzer 19 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 20Speech 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.htmlTraumatic 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 thatChelsea 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. Pitzer 21Speech-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 tbsp5/15: 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.5/14Food 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 320 13gInstant Breakfast with 2% milk 1 cup Mashed Potatoes ~200 4g 2 tbsp gravy 15 0g Total ~775 ~28 225/151 cup cheerios 100 3g 1 cup whole milk 150 8g 240 cc CIB with 2% 320 13g milk 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% 320 13g milk Total ~1,200 ~50Average kcals Average protein ~990 ~40 b. What recommendations would you make regarding her enteral feeding at this time?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. Pitzer 23SourcesEducation 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 PediaSure® 1.5 Cal. (n.d.). Retrieved October 23, 2014.Result Filters. (n.d.). Retrieved October 23, 2014, from http://www.ncbi.nlm.nih.govSigns 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.orgSpeech Therapy Training. (n.d.). Retrieved October 23, 2014, from http://link.springer.com/chapter/10 24Stress. (n.d.). Retrieved October 23, 2014, from http://www.diabetes.orgTraumatic Brain Injury (TBI). (n.d.). Retrieved October 23, 2014, from http://www.asha.org/public/speech/disorders/TBI/Work Cited Pitzer 25Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/traumatic-brain- injury/basics/definition/con-20029302Brainline. http://www.brainline.org/content/2010/10/what-is-the-glasgow-coma-scale.htmlPedmed http://www.ncbi.nlm.nih.gov/pubmed/15561417Brain Injury Institute. http://www.braininjuryinstitute.org/Brain-Injury-Types/Frontal-Lobe-Damage.htmlPubmed http://www.ncbi.nlm.nih.gov/pubmed/19033220Brainline. http://www.brainline.org/content/2010/12/feed-your-body-feed-your- brain-nutritional-tips-to-speed-recovery.html

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