BURNS: LET'S BEGIN AT THE BEGINNING…
By: Paula K. Burke, RD,LD
It is my great privilege to start a series of articles for Burn Survivors Throughout The World, Inc.. It seems that as I begin this series, a good place
to start would be to share with you some of the information that is used by the Registered Dietitian (R.D.) to assess the nutritional status of an individual who presents to the hospital with a severe burn injury.
The dietitian uses the nutritional assessment to develop an individualized nutrition care plan. The nutrition care plan includes recommendations for medical nutrition therapy that becomes a part of the overall therapy plan of the health care team led by the physician in charge.
Medical Nutrition Therapy is considered a "supportive" measure. A dietitian is trained to understand that nutrition is the foundation of both the structure and the function of every cell in the human body. If optimal nutrition promotes optimal function,
then the opposite is also true: sub optimal nutrition will not promote optimal function. The definition of 'optimal' can vary dramatically by the situation in which the body finds itself. When the body is in danger, as it is when it is threatened by severe illness or injury with severe burns, nutrition
plays a critical role.
THE NUTRITION ASSESSMENT
The nutritional requirements of a person can be very different and depends on the whole person and their situation. The dietitian uses the ABC approach to assess the nutritional status of a person.
A = Anthropometric Measures
Anthropometrics include Height and Weight. Weight is generally considered in proportion to Height, with an Ideal Body Weight (IBW) being used as a frame of reference. The IBW is based on age, gender, and frame size. The estimated daily calorie and protein
needs are calculated based on the person's weight.
It is important to remember that the skin is one of the most important organs in the body when it comes to preventing dehydration. When a large portion of a body's skin surface is destroyed by burns, it can be very difficult to keep enough fluid in the body and
to keep it working properly. Ideally, the dietitian will know the usual weight of the person before the burn injury. It is this weight that the dietitian prefers to use because it gives a better idea of whether the person was of normal weight, underweight or overweight before the burn injury. Although height
remains the same, weight changes, and can change dramatically when a person has been severely burned. The weight of a person can change up or down by 30 pounds or more because of the amount of body fluid a person has lost or gained. This is because 1 liter of fluid weighs about 2.2 lbs.
This is important to know when calculating calorie, protein and fluid needs. If the usual body weight is not known, the 'dry' body weight that is obtained on admission to the hospital will be used for calculations as compared to what is known as the 'wet' weight that occurs during or after fluid
resuscitation. A dietitian closely watches the weight of the patient throughout the hospital stay.
B = Biochemical Measures
Blood work is done on all people hospitalized with severe burn injury. The blood that is drawn from a patient is sent to the laboratory where the blood levels of many substances can be measured. What substances are measured depends on what the physician and other members of the health care team
want to see. This includes 'electrolytes' such as sodium, potassium, calcium, and magnesium as well as different blood proteins. The blood levels of these substances are very important in letting the health care team know how the body is responding to the different therapies being provided. These therapies include medical, nutritional and drug therapy.
C = Clinical Indications
The dietitian also wants to know other important information about the person. This information includes the medical history. The medical history tells the dietitian whether this person was completely healthy before the burn or whether the person has other medical conditions before or since the burn injury. The
medical history also lists any medications, vitamins, minerals or other dietary supplements the person may currently be taking or were taking prior to the injury. These facts are very important is helping the dietitian to assess the nutritional status of the patient, develop the medical nutritional therapy care plan and in monitoring the patient's response to therapy.
THE NUTRITION CARE PLAN
The care plan is developed to provide adequate nutrition support via medical nutrition therapy with the following goals:
1. Provide adequate nutrition (calories, protein, fluid, vitamins, and minerals) to meet the nutritional needs of the patient. The goal of optimal nutrition is to meet the body requirements of an individual without underfeeding OR overfeeding the patient. Both underfeeding and overfeeding places an undesirable stress on the body.
2. Minimize the loss of lean body tissue. When the body is in a stress response such as with severe burn injury, the body does not use stored fat tissue to provide energy for the body; instead the body starts to break down muscle tissue for energy when the body is in the stress response. When the body is properly fed, the breakdown of muscle can be slowed down.
3. Prevent weight loss of more than 10% of the usual body weight before the burn injury. Some weight loss is unavoidable, but the goal of medical nutrition therapy is to keep this weight loss to a minimum. In a person that weighs 100#, this would mean that when the person came out of the critically ill phase of the burn injury, the person would not weigh less than 90lbs.
4. Provide adequate nutrition that will assist wound healing and help prevent infection.
The dietitian develops the care plan to meet these goals by calculating an initial or starting point of estimated nutritional needs for a person. The first step in the plan is to reach the point where the person is actually taking in 100% of the estimated needs. For the first 72-96 hours the person will usually not be able to eat and will be undergoing fluid and electrolyte replacement. The person may
need to be fed with an IV or feeding tube early on. Until the patient is discharged from the hospital the dietitian will be monitoring the patient in several ways to be sure that the 4 goals of nutrition support are being met. These include:
1. Daily calculation of the amount of calories and protein the person is taking in via a Calorie Count.
2. Monitoring fluid intake and output daily.
3. Monitoring weights that are measured at least twice a week for changes.
4. Monitoring changes in blood work or 'Labs'.
5. Monitor the progress of wound healing.
6. Monitor for signs and symptoms of infection.
The dietitian will recommend to the physician any changes in medical nutrition therapy that would be appropriate and desirable for the patient.
We have now come to the end of the beginning, which is the period of time immediately after the severe burn injury when the patient is in the critically ill stress response phase. This is the period of time where the person may be unconscious or sedated to the point where they may be unaware of what is truly happening to them. The nutritional needs of the patient do not go away after this beginning however, as
you well know. The ability to take in enough calories and protein can be very challenging. Next time we will discuss ways and means to achieve this. This is when the person is actually eating real food on their own again, whether in the hospital or at home!
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