Sunteți pe pagina 1din 16

Pancreatic Cancer Patient

72 year old female presented with abdominal pain, anorexia, indigestion and jaundice in October to her
PCP. Patient then underwent CT, lab work, and an ERCP (endoscopic retrograde
cholangiopancreatography). Patient had biliary stents placed. Results of the tests indicated patient to
have unresectable pancreatic cancer. She was treated with FOLFIRINOX (beginning in January)
rescanned and found to be resectable. Please note, during treatment patient complained of loose
bowel movements that were frequent and had an oiliness to them.
April underwent a total pancreatectomy, splenectomy, SMV resection. Pt was found to have positive
margins and then on began single agent gemcitabine (1 cycle) with initiation on 6-29 of weekly
gemcitabine plus radiation.
Ht: 166.7cm (56)
Wt history:
1/7 = 92.6kg
3/25 = 95.1kg
5/27= 87.8kg
7/8= 82.3kg
11% wt loss x 6 mo
8/5= 79kg
14.7% wt loss x 7 mo
10% wt loss x 3 mo
4 % wt loss x 1 mo

DBW: 59.1

% DBW: 133 (at 79kg)

ABW: 64.1kg

Labs from 8/5: glu 135, Na 130, K+ 4.0, cl 90, BUN 11, cr 0.51, alb 3.2, ca 9.0, alk phos 101, AST 26, ALT
20, T bili 1.5
Questions
1) What is FOLFIRINOX? And what side effects would you expect from this?
FOLFIRINOX is a combination chemotherapy regimen for patients with exocrine pancreatic
cancer recommended, especially for pt with mets. A cycle length is 14 days and it is composed of
four different drugsoxaliplatin, leucovorin, irinotecan, and two doses of fluorouracil. Because
the chemotherapy will cause a drop in WBC, pt are at increased risk of infection and are often
fatigued due to low RBC as well. Other side effects include mucositis, hair loss, diarrhea,
abdominal cramping, loss of appetite, blurred vision, nausea, vomiting, fatigue, and skin rashes.
Chemotherapy-related hepatotixicty and nephrotoxicity may also occur.
2) After her surgery please tell me what diet you would place her on for discharge and what you
would want to monitor?
For discharge, I would recommend the patient to maintain a low-fat diet with small frequent
meals. It is important to monitor levels of fat-soluble vitamins and B12. I would also monitor
tolerance to fat in regards to dose of pancreatic enzymes.
3) Patient is placed on pancreatic enzymes- why? What questions would you ask and what
symptoms would you use to determine if she is getting adequate enzyme replacement?

Pancreatic enzymes include a mixture of amylase, lipase, and proteasedigestive enzymes.


Because the patient has had a total pancreatectomy, she will be deficient in these enzymes and
will not be able to properly digest and absorb food, especially fats. Symptoms to monitor
regarding adequate enzyme replacement are diarrhea, bloating, gas, cramping/pain after meals,
fatty stools, foul smelling stools, and weight loss. These symptoms may indicate that she is not
taking enough pancreatic enzymes with meals. The general practice is for every 5 g of fat in
meal, take an enzyme.
4) Assess her nutritional needs based on the data provided.
Kcal: 1800-1950 (28-30 kcal/kg of ABW)
Pro: 80-90 (1.2-1.4 g/kg of ABW)
5) What do you feel her nutrition Diagnosis would be with the information you have from 8/5?
What other information would you like to have to formulate your diagnosis?
Based on her weight history up to 8/5, I would suspect that she has some degree of malnutrition
in setting of weight loss with increased needs of her hypermetabolic disease state and
malabsorption d/t total pancreatectomy.
Diagnosis 1: Moderate protein-calorie malnutrition r/t altered GI function in setting of
hypermetabolic disease state AEB 14.7% wt loss x 7 months (significant), frequent loose
stools, and moderate muscle and fat losses.
Diagnosis 2: increased nutrient needs r/t disease state AEB increased metabolic
requirements necessary to meet catabolic demand and prevent further nutritional
decline
To validate my diagnosis, I would like to know how her appetite and PO intake has been. I would
also want to know the results of a NFPE concerning adipose stores and muscle wasting.
6) What would you assess / monitor at follow up?
At follow up, I would assess/monitor her tolerance to a low-fat diet with small frequent meals
t/o day. I would also monitor pancreatic enzyme use, PO intake and tolerance, digestive
function, weight trend, stool output, mealtime behavior, and labs (B12 and fat-soluble vitamins).
If she started to supplement B12 and fat-soluble vitamins already, I would asses her vitamin
regimen/intake.
Resources: Up-to-date, NCM, Oncology lecture, https://pancreaticcanceraction.org/about-pancreaticcancer/treatment/enzyme-replacement/, https://www.pancan.org/section-facing-pancreaticcancer/learn-about-pan-cancer/diet-and-nutrition/pancreatic-enzymes/

HSCT Case Study:


Pt is a 54 year old male admitted to the hospital for initiation of Salvage chemo (Clofarabine) for
relapsed AML. (3/30/12)
PMHx: AML s/p induction chemo with 7 + 3 followed by 3 cycles of consolidation chemo (using high
dose Cytarabine). 1st complete remission (CR) (11/2010) , 10 months later with dz relapse and received
Salvage chemo , s/p RIC reduced intensity conditioning- MUD allo PSCT (9/30/11) leading to a 2nd CR.
Additional hx includes: DVT, Depression, and chronic Grade II GVHD of the skin.
Patient was eating well with good appetite until 2 weeks ago. Prior to this, he was consuming a healthy
diet that included whole grains, fresh fruits and veggies, and fish. He is primarily vegetarian but will
consume some fish and dairy products. He has always avoided anything artificial and was walking
several miles per day. Since hes been admitted he is experiencing more weakness in his lower
extremities and having difficulty walking. He has been refusing oral nutrition supplements throughout
his hospital stay, despite poor appetite and taste changes. In addition, hes now developed profuse
watery diarrhea and remains with suboptimal oral intake.
24 hour recall includes: Strawberries, raspberries, blackberries, and Mango (brought in from home), in
addition to some clear fluids.
He currently c/o diarrhea, abdominal pain/cramping, and intermittent nausea.
-C. diff Negative.
-s/p Colonoscopy + Grade IV GVHD (gut)
Diet: Full liquids
Pertinent labs: Na 135 L
K 3.2 L
Cr .46 L
Phos 2.3 L
PAB 16.9 L
Trigs: 386
Serum Ca: 6.8 L
UBW: 1 year ago 74.2 kg, 10/2011: 72.6 kg
Hospital Admission: 3/30/12: 67.7 kg (admit)
4/24/12: 62.7 kg (still in hospital)
4/26: 61.8 kg (Still in hospital)
8.7% wt loss x 1 mo (since admit)
14.9% wt loss x 6 mo
16.7% wt loss x 1 year
*Significant wt loss
Meds: Imodium, Octreotide, Cellcept, Methylprednisone, Actigall, Nexium, Acyclovir, Prochlorperazine,
Esomeprazole
*Requiring Daily K and Magnesium Supplementation.

IVF: D5 NS @ 100 mls/hr continuous


24 hour Stool Output 900 mls
Consult received for full nutrition assessment and recommendations Questions
1. What is the patients nutrition diagnosis and what data would you use to support it (may include
your PES statement)?
Due to weight loss, weakness, and difficulty with normal activity, I am assuming that the patient
has had moderate muscle and fat losses.
Diagnosis 1: Moderate protein-calorie malnutrition r/t suboptimal PO intake and GI
issues (D/N/anorexia/taste changes) in setting of hypermetabolic disease state AEB
16.7% wt loss x 1 year (significant), inadequate protein/kcal intake, poor appetite, and
moderate muscle and fat losses.
Diagnosis 2: increased nutrient needs r/t disease state (AML, GVHD) AEB increased
metabolic requirements necessary to meet catabolic demand and prevent further
nutritional decline
2. Calculate estimated calorie and protein requirements.
Current weight: 4/26 61.8 kg current height:_______
Calories: 1850- 2150 (30-35 kcal/kg for GVHD) if on TPN, 1700-1800 kcal as to not overfeed
Protein: 95 120 (1.5-1.9 g/kg for GVHD)
3. Please describe your nutrition interventions, including specifics regarding diet, education, oral
nutrition supplements etc.
Diet: If team feels that TPN is appropriate, 5/15 80 mL/hr x 24 hr with 10 mL lipid (1863
kcal, 96 g pro) to meet 100% of pts needs
Education: Emphasized importance of high kcal, high pro foods in order to maintain
body weight and preserve LBM. Encouraged PO intake and to eat small frequent meals
t/o day. Provided pt with Diarrhea Management handout
Oral nutrition supplements: Offered Resource Breeze and magic cup to pt; pt declined
use of supplements
Additives: Offered pro-stat to pt; pt declined. Provided nutrifiber packet
4. List specific nutrition recommendations you would include for the physician team.
When medically appropriate, advance diet from full liquids to low pathogen to promote
PO intake.
If TPN required to resolve gut GVHD, please provide day 1 at goal of 40 mL/hr x 24 hr.
If tolerated, advance to goal of 80 mL/hr x 24 hr with 10 mL lipids
Additional 7 mg zinc needed in TPND bag for repletion x 10-14 days
Please discontinue D5
Monitor lytes, Mg, Phosreplete PRN
Check TG at baseline and once a week there after; if TG > 400, supply lipids on M,W,F
Check 25-OH Vit D level; replete if less than 20
Provide 1 mg zinc/ 100 ml stool when stool volume > 900 mL
If not on TPN
Centrum Silver daily
Consider Ca + D supplementation BID (Ca levels low and pt on steroids)

5. List the possible nutritional side effects for the patients listed medications, including
Clofarabine, the most recent chemo he received.
Clofarabine: N/V/ abdominal pain/ loss of appetite/ gingival bleeding/ mucositis/ oral
candidiasis
Imodium: constipation
Octreotide: abdominal pain/ loose stools/ N/ V/ gas/ cholelithiasis (depending on length
of therapy)
Cellcept: abdominal pain/ N/ V/D/C/ loss of appetite/ dyspepsia
Methylprednisone: increased appetite/ weight gain/ distention/ N/ V/dyspepsia/
increased blood sugar/ stomach pain
Actigall: N/V/D/C/ loss of appetite/gas/ bitter taste change
Nexium: D/ C/ gas/ bloody or black stools/ N/ V
Acyclovir: N/V/D
Prochlorperazine: increased appetite/ C/ N/ V/ weight gain/ xerostomia/ ileus
Esomeprazole: gas/ D/ abdominal pain/ N/ xerostomia/ C
References: Up-to-date, SCC 3 unit guideline, HSCT lecture

Esophageal Case Study


44 year old AA gentlemen with a PMH of alcoholism, 1 ppd smoker, HTN and GERD. The patient is a poor
historian with poor social/environmental circumstances. Initially p/w significant weight loss, inability to
swallow and SOB with a concern for aspiration PNA. The patient received the following test and
procedures: lab work, EGD, chest x-ray, PET, MBS, mediport and PEG placement. Work-up confirmed
widely metastatic esophageal CA. The patient is not a surgical candidate. The patient was treated for
aspiration PNA with Abx, received palliative radiation to the distal esophagus and was started on
nutrition support.
Labs: Glucose 89, Na+ 134 (L), K+ 4.8, Chloride 97 (L), Bicarbonate 28, BUN 10, Cr 0.68, Calcium 8.6, Phos
4.3, Albumin 2.2(L). Alk Phos 252(H), AST 22, Total Bili 0.6
Height: 182.8cm (72)
Weight: 60.6kg (133#)
Weight Loss PTA: 30-40# (No previous weight records)
DBW: 80.9

%DBW: 75

Questions
1. Describe the acute effects and long term effects of radiation therapy
Acute effects of radiation therapy include burning of the skin (resulting in breakdown, dryness,
flakiness, swelling, blistering, etc.) and underlying tissues. So, for esophageal CA, radiation will
have an impact on the ability it eat. Radiation treatment for other cancers such as lung, and
head and neck cancers will also impact eating. Any radiation done to the
esophagus/mediastinum area, or mouth- upper and/or lower palates- can make it difficult and
painful to chew and/or swallow. Radiation to or near the stomach or intestines can also cause
eating problems. Mucositis may occur as well as nausea, vomiting, dysphagia, taste change/loss
or loss of appetite. These effects translate into weight loss. Radiation may also cause fatigue and
hair loss (depending on where the radiation is targeting).
Long term effects of radiation include risk of developing another cancer from treatment
exposure and also damage to organs receiving treatment. Lymphedema may also develop.
2. What does widely metastatic cancer mean?
According to the National Cancer Institute, metastatic cancer indicates that the disease has
spread from the primary site of where the cancer started to other organs and parts of the body
not directly connected. For example, small cell lung cancer frequently metastasizes to the brain
so the oncologist will offer prophylactic radiation therapy to the brain.
3. What are the risk factors for esophageal CA?
There are two main types of esophageal CAsquamous cell carcinoma (SCC) which usually
occurs in the upper 2/3 of the esophagus and adenocarcinoma which usually occurs in the lower
1/3 of the esophagus. Risk factors for the two CA differ; smoking, alcohol use, HPV, and H. Pylori
are risk factors for developing SCC while GERD, obesity, and Barretts esophagus are risk factors
for developing adenocarcinoma.

4. Calculate the patients calorie, protein and fluid requirements


Kcal: 1800-2100 (30-35 kcal/kg) Pro: 75-90 (1.25-1.5 g/kg)

Fluid: ~1800 mL or per MD

5. What is the nutrition diagnosis for this patient?


Diagnosis 1: Severe protein-calorie malnutrition r/t altered digestive function in setting of
hypermetabolic disease state AEB inability to swallow, requirement of PEG tube, 75% of
DBW, elevated protein and kcal needs necessary to prevent further catabolism
6. Please describe in detail the patients nutrition support recommendations
Choose a TF formula that is most appropriate for this patient
Isourouce 1.5 would be appropriate for this patient. Most insurances cover Isosource
1.5 and it is indicated for patients with elevated kcal and pro needs. In the setting of the
widely metastatic esophageal CA, this pt has elevated kcal and pro needs. If this patient
was a candidate for surgery and had his esophagus removed, I would have selected
Peptamen 1.5 instead of Isosource. This is because Peptamen 1.5 is indicated for
patients with GI impairment. However, since the patient did not undergo surgery, it
would be easiest to start and continue Isosource 1.5 in house to home-going to monitor
tolerance and progress on the same product.

Calculate the TF rate and water flushes that will meet the patients estimated calorie,
protein and fluid requirements
55 mL/hr x 24 hr (1980 kcal, 90 g pro, 1027 mL free water, 1320 mL total volume)

What labs will be monitored and why?


Electrolytes should be monitored (including magnesium and phosphorus) as well as
blood glucose levels. Electrolytes provide insight into fluid status and renal function;
magnesium and phosphorus help to identify risk of refeeding syndrome; and, glucose
indicates glycemic control.

Set up a home TF Regimen for this patient (List the TF supplies that the patient will need
to administer his TF)
The patient may either use the bag method or the syringe method for feeding. If the
patient chooses the bag method, he will need his feeding bag and tubing, IV pole or
hook, formula, 60 mL syringe, an empty cup, and a cup with enough room temperate
water for 2 flushes. If the patient chooses the syringe method, he will need 60 mL
syringe, formula, and a cup with enough room temperature water for 2 flushes.
Home TF regimenIsosource 1.5: 310 mL 4x day (1860 kcal, 84 g pro, 965 mL free
water, 1240 mL total volume) with 60 mL water flush pre/post and additional 250 mL
water flush once throughout the day.
Cans per day: 5

How will TF tolerance be monitored?

TF tolerance will be monitored via labs in part c (above) during in-patient care. Once the
patient is discharged and is administering tube feed at home, tolerance may be
monitored by checking stomach residuals prior to feeding. If gastric residuals are high
(over ~200-500 mL) this indicates that gastric emptying is very slow and more formula
should not be given at this time. Tolerance can also be monitored by noting any GI
symptoms such as diarrhea, dehydration, constipation, and/or nausea
7. The patient does not have health insurance. Please list at least two resources available to help
this patient receive TF at home.
One resource available to help this patient receive TF at home is the Oley Foundation. Patients
may also receive TF at home without insurance through the Nestle HealthCare Patient
Assistance Program.
8. List two nutrition goals for this patient. How would you assess/monitor these goals on followup?
Tube feed tolerance: monitor digestive function; evaluate whether pt has been
experiencing any GI issues
Maintain stable weight: compare initial visit weight to follow-up weight; ensure that
nutrition support is meeting 75% of nutrient needs.
References: American Cancer society, Oley Foundation

GYN Case Study


Mrs. S. is a 68 yo female who was diagnosed in July 2015 with stage III ovarian cancer and is s/p
total abdominal hysterectomy and bilateral salpingo-oophorectomy. Following recovery from
surgery, she was started on Carboplatin-Taxol chemotherapy, given 1 cycle of treatment every
3 weeks. In October, she presented to the ED with one month history of poor appetite, N/V as
well as weakness and was admitted for FTT.
RDN/LD went to visit patient for an assessment. Mrs. S. reports nausea and vomiting, starting
about three days following treatment and lasts for 1- 1.5 weeks. Her fatigue is increased after
treatment and as a result, she has a difficult time making her own meals. She also describes
some taste changes and is sensitive to smells. Mrs. S. says that nothing appeals to her. Per
patients subjective reports, her typical intake consists of 6 oz Greek yogurt for breakfast, 1
Ensure Plus supplement in the afternoon, and 1 cup of chicken noodle soup for dinner.
Onco hx:
July 2015: stage 3 moderately differentiated adenocarcinoma of the ovary
PMH: HTN, LE DVT
PSH: appendectomy, TAH BSO
Medications: oxycodone, reglan, magnesium gluconate, colace, megestrol, senna,
pantoprazole, K-tab, metoprolol, mirtazapine
Height:
165.1 cm

Weight hx:
04/09/2015 58.0 kg
08/06/2015 53.2 kg
10/15/2015 49.4 kg

DBW: 56.8 kg

Case Study Questions:


1. Calculate the percent weight change. Would this degree of weight loss be considered
significant?
From April to October, percent weight change in 14.8%. In a 6 month time, a percent
weight change greater than 10% is significant. Thus, her weight loss is significant. From
August to October, her percent weight change is 7.1% which is also significant in a two
month timespan.
2. What are the patients estimated calorie and protein needs? What percentage of her
estimated needs are being met with current intake?
Kcal: 1300- 1500 (26-30 kcal/kg)
Pro: 60-70 (1.2-1.4 g/kg) based on TAH in
setting of ovarian CA
6 oz greek yogurt: 160 kcal, 11 g pro
Ensure plus: 350 kcal, 13 g pro

1 cup chicken noodle soup: 90 kcal, 9 g pro


Total: 600 kcal, 33 g pro. This is ~ 43% of her kcal needs and ~51% of her protein needs.
3. Write a PES statement for this patient.
Diagnosis 1: Moderate protein-calorie malnutrition r/t inadequate PO intake in setting
of chronic illness and effects treatment AEB 14.8% wt loss x 6 months (significant), poor
appetite, N/V, fatigue, deconditioning, and inability to meet needs with PO intake.
4. What are some potential side effects of Carbo-Taxol? Name at least three tips you
would discuss with this patient for symptom management.
Some potential side effects of Carbo-Taxol are nausea/vomiting, diarrhea, and
mucositis. Because pt is also experiencing loss of appetite and taste changes, I would
touch upon these topics as well. For her N/V and loss of appetite, I would suggest eating
small, frequent meals throughout the day with high kcal, high pro foods easily accessible
such as cheese and crackers, peanut butter and jelly sandwiches, and ice cream. I would
also recommend for her to drink her liquids separate from eating meals/snacks to
prevent early satiety. For her diarrhea, I would recommend for her to continue eating
yogurt and also suggesting foods such as cream of wheat and rice and to avoid greasy/
fatty or fried foods. For her mucositis, I would recommend soft foods such as yogurt,
mashed potatoes, milkshakes/smoothies, bananas, applesauce, and cooked cereals. To
help with taste changes and sensitivity to smell, I would recommend eating foods more
at room temperature with less spice if the flavor is upsetting her stomach. If she is
complaining of no flavor, I would suggest adding extra herbs and spices to her food. I
would also suggest using plastic utensils for eating.
5. What are your nutrition interventions for this patient?

Individualized nutrition prescription provided for diet


Ordered supplements: Boost Plus TID (360 kcal, 14 g pro each)
Provided diet education on side effects of chemo and eating small frequent
meals (see recommendations above in question 4)
I would also suggest to the team to initiate an appetite stimulant

6. What are your goals for this patient? What are some things you would monitor for to
see if patient is meeting her goals?
Goals: PO intake greater than or equal to 75% of meals, consume 3 oral supplements
per day, daily improvement in po intake/tolerance, maintain stable weight with gradual
weight gain.
Monitoring: PO intake and tolerance, weight trend, mealtime behavior, overall
appearance.

Mrs. S. was discharged from the hospital and continued to receive chemotherapy. She
completed 6 cycles of Carbo/Taxol. She returned to the outpatient clinic during routine follow
up and was found to have increasing abdominal girth, recent weight gain, and shortness of
breath. Mrs. S. was admitted to the hospital for further workup.
Onco hx:
July 2015: stage 3 moderately differentiated adenocarcinoma of the ovary
PMH: HTN, LE DVT
PSH: appendectomy, TAH BSO, s/p 6 cycles of adjuvant Carbo/Taxol
Medications: oxycodone, reglan, magnesium gluconate, colace, megestrol, senna,
pantoprazole, K-tab, metoprolol, mirtazapine
Height:
165.1 cm

Weight hx:
04/09/2015
08/06/2015
10/15/2015
01/15/2016

58.0 kg
53.2 kg
49.4 kg
53.6 kg

This patients most recent PET scan shows metastasis to the liver and malignant ascites. She
had 4 L of fluid removed during paracentesis and now weighs 48.2 kg. You went to visit her to
assess nutrition status. She feels weak and now reports early satiety and poor appetite.
7. Calculate her energy needs. Identify which weight you would use to make your
estimations and why.
Kcal: 1350 1450 (28-30 kcal/kg)
Pro: 60 70 (1.2 1.45 g/kg)
These needs are based off her weight of 48.2kg after fluid has been removed. I based
her needs off of this weight because it reflects true weight loss and not fluid status
changes.
8. What are some suggestions you could make to help her meet her estimated
energy/protein needs?
In order to meet energy/protein needs, I would suggest that she eat small frequent
meals/snacks throughout the day consisting of high kcal-high pro foods. Examples of
such meals/snacks include Greek yogurt with fruit, peanut butter and jelly sandwiches,
smoothies/milkshakes with whole milk, scrambled eggs with cheese, and dishes with
sourcream/extra gravy/butter/ salad dressing, etc. Also, I would recommend she try
nutritional supplements such as Resource Breeze, Boost Plus and/or Pro-stat. If she is
unable to meet her needs orally in the hospital, I would suggest an overnight TF regimen
to help prevent further weight loss and wasting.
9. With the new findings on PET scan, patient now has Stg. IV disease. If the patient is
transitioned to hospice care, would your nutrition goals change?

If the patient is transitioned to hospice care, my nutrition goals would change. Rather
than preventing further nutritional decline, I would instead focus on comfort through
nutrition. I would ask the patient if she is interested in any nutritional supplements for
her comfort.

Lung Cancer Case Study


Mrs. L is a 76 y o female diagnosed with Stage IV Squamous Cell Carcinoma of the lung with a
single lesion in the brain. She is pending Gamma knife radiosurgery. She is currently receiving
palliative RT to the chest wall/mediastinum. Patient refused chemotherapy.
PMH: Benign Essential Hypertension, NIDDM, Hyperlipidemia, Asthma, and GERD
Mrs. L is 162.6 cm in height (54) and weighs 67.8 kg today.
Previous recorded weights: 70.5 kg (6 weeks ago)
3.8% wt loss
75.8 kg (4 months ago)
10.6% wt loss
DBW: 54.5kg %DBW: 124
There are no recent labs.
HGB A1C from last month:

6.8 % (Reference range: 4.2-6.3 %)


Average glucose: 148 mg/dL

No allergies.
Medications: Omeprazole (40 mg daily), Metformin (500 mg t.i.d.), Hydrochlorothiazide,
Lisinopril, Pravastatin, ProAir inhaler, Nystatin, and Mirtazapine
Mrs. L presented at diagnosis with anorexia and weight loss. Today she continues to lose
weight and c/o odynophagia when swallowing- even when swallowing water. She rates her
pain at an 8/10. Her intake is poor, reporting one egg, C of mashed potatoes, a slice of
watermelon and 1 each 16.9 oz. water bottle all day yesterday.
She does not check her BS regularly, however, her homecare nurse performed a finger stick 2
days ago in the a.m. and found her level to be 59 mg/dL.
Physical findings deferred- white, patchy tongue on exam per RN/MD.
Case Study Questions:
1. Calculate Mrs. Ls estimated nutritional needs for calories, protein and fluid.
Kcal: 2100-2400 (31-35 kcal/kg)
Pro: 90-100 (1.3-1.5 g/kg) Fluid: ~2000mL or per MD
2. What is/are Mrs. Ls nutritional diagnosis?
Increased nutrient (protein-kcal) needs r/t GI issues (odynophagia, possible thrush) in
setting of hypermetabolic disease state AEB 10.6% wt loss x 4 mo, loss of appetite, poor
PO intake, elevated protein and kcal needs required to prevent further catabolism
*If weight continues to trend downward and pt unable to tolerate PO intake, on low
threshold of mild PCM

3. What would your intervention be with regard to her diet?


If the team prescribers her medication to help manage the odynophagia, I would recommend
that she try a soft diet. Soft, cool, and moist foods may be better tolerated with the swallowing
pain. Soft/pureed foods may also be easier to eat in general if she does not have an appetite
since there is less effort needed to chew. However, because she is already consuming a
relatively soft diet, she may need enteral nutrition if the pain continues to worsen and she is not
able to tolerate anything by mouth.
4. What other interventions would be appropriate with regard to symptom management/ overall
intake?
To promote overall intake, I would suggest eating small frequent meals, every 2 hours. These
meals should consist of high kcal, high pro foods, preferably soft/pureed if that is all she can
tolerate. Examples of such foods include peanut butter, hummus, scrambled eggs, milkshakes
made with whole milk, Greek yogurt, tuna/chicken salad, casseroles, meatloaf, and cream-based
soups. I would also recommend that she start a nutritional supplement regimen such as taking
Boost Glucose Control/Ensure or Pro-stat. I would suggest trying to take ~3 nutritional
supplements/day in between meals as to not induce early satiety. Additionally, to manage her
blood sugars, I would recommend that she try to eat a carbohydrate every time she eats, paired
with a protein. In order to help with the pain, I would recommend that she does not eat spicy
foods or foods served at high temperatures. It may be easier to tolerate foods served at room
temperature or cold foods such as ice cream.
5. Which of Mrs. Ls medications do you think were added to her regimen after her cancer
diagnosis and why? Do you have any recommendations for changing or adding to Mrs. Ls
current medications?
Omeprazole is a PPI used to treat heartburn, GERD, stomach ulcers, and esophageal damage.
Although she has PMH of GERD, the radiation to the mediastinum may have also affected the
esophagus (also evidenced by odynophagia). Thus, omeprazole might have been added to her
regimen after CA diagnosis to help with the damage to the esophagus caused by the radiation.
Nystatin, a medication used to treat fungal infections, was also probably prescribed after cancer
diagnosis. The physical findings of white patchy spots on her tongue may be thrush; nystatin can
treat the thrush.
Mirtazapine (aka remeron) is an appetite stimulant and also can treat depression. This was
probably added after cancer diagnosis since she now p/w loss of appetite and weight loss.
Besides what she is already on, I would recommend BMX to help with her swallowing pain. If not
BMX, maybe oxycodone; or, a combination of BMX and oxycodone, depending on what her
doctor thinks is appropriate.

Head and Neck Case Study


4/16/15: 56 y/o Male with oropharyngeal (tonsillar) cancer presents to Medical Oncology clinic for initial
consultation. Hes 6 0 tall and weighs 78.6 kg, which is normal for him. 2 weeks ago he had a triple
endoscopy with biopsies. Today, he complains of a sore throat, but it does not seem to inhibit his
intake. He usually skips breakfast and eats fast food for his other two meals. Currently denies any
N/V/D/C. His teeth are in poor condition, and he hasnt seen a dentist in years. Next week he will have
all of his remaining teeth pulled in anticipation of beginning concurrent daily radiation therapy + weekly
cisplatin which will last for 7 weeks.
4/16/15: 78.6 kg initial consult
5/5/15: 80.1 kg start of radiation
5/19/15: 76.2 kg
5/26/15: 77.1 kg
6/2/15: 72.5 kg
6/9/15: 68.1 kg
6/15/15: 65 kg
6/23/15: 66.7 kg
6/29/15: 65 kg

Case Study Questions:


Based on the initial data from 4/16/15:
1. What would your initial interventions be to prepare this patient for treatment?
At 60 tall and 78.6 kg, the pts DBW is 80.9 kg; this makes him currently 97.2% of his DBW. To
prepare for his treatment including teeth extraction and concurrent daily radiation therapy with
weekly cisplatin, I would encourage the pt to increase his protein and kcal intake. First, I would
recommend that he eats something for breakfast and that he does not eat fast food for his
other two meals. I would educate on healthy high kcal, high pro food/meal options. If need be,
he can do small frequent meals throughout the day if he doesnt like large meals. Since it
appears that his nutrition isnt ideal, I would also encourage the pt to start a Boost Plus regimen
at home TID. The pt may also be a candidate for a prophylactic PEG.
2. Assess his anticipated calorie, protein, and fluid needs for when he is undergoing treatment.
I am basing his kcal, pro, and fluid needs with his 5/5 weight80.1kg since this is when he starts
radiation
Kcal: 2400 2600 (30-32 kcal/kg) pro: 100 110 (1.2-1.4 g/kg) fluid: ~2400 mL (30 mL/kg)
3. What electrolyte(s) would you choose monitor in this patient receiving cisplatin? Which one can
be easily supplemented via PEG tube?
Cisplatin may decrease potassium, zinc, calcium, sodium, and phosphorus. Cisplatin may also
severely decrease magnesium, resulting in a loss of body Mg. Sodium can be easily
supplemented via PEG tube by adding a tsp of table salt into a water flush.
6/9/15: you note the patient is having increased difficulty eating. He has thick mucus, which is making it
impossible to swallow oral supplements. Hes also struggling with grade 2 mucositis and thrush causing

odynophagia. His skin is beginning to break down as well. Pain is controlled with oxycodone 10mg q 4
hrs.
4. Given his current symptoms, which of his previously assessed nutrient needs (question2) might
increase?
At this point, the pt has elevated protein needs. Because he is experiencing mucositis, thrush,
and unable to swallow oral supplements, he is probably losing weight resulting in the loss of
lean body mass. Additionally, extra protein is needed for his skin breakdown.
5. Provide a home PEG tube feeding and free water schedule for this patient. Include formula,
amount, and administration method.
At home, the patient should use Isosource 1.5, 4 times daily via the syringe method if he is
comfortable with that.
405 mL 4x day (2430 kcal, 110 g pro, 1260 mL free water, 1620 mL total fluid) with 60 mL water
flush pre/post and two additional 250 mL water flushes in between feeds.
Cans per day: 6.5 if the patient finds it easier, do 1.5 cans for 3 feeds and then on the fourth
feed, do 2 full cans to equal 6 cans.

S-ar putea să vă placă și