NUTR 4408 GAHN 6408 Medical Nutrition Therapy
NUTR 4408/GAHN 6408: Medical Nutrition Therapy
Group Case Study
Elderly female with advanced oral cancer
By:
Weam Alamoudi
Erada Alghamdi
Manal Alzubiadi
Submitted to: Dr. Theresa Glanville
5November 2013
Laboratory results for IM:
Lab tests Reference
Range (5) IM’s
Histroy Comments
07/29 08/31 09/12 Albumin (g/L) 35-50 34 33 29 Decreasing gradually, and this is most
likely due to malnutrition in relation to
poor dietary intake and low protein
consumption.
Hbg (g/L) (130-180) 84 – 97 Gradual slow increase in the last lab result,
may be due to addition of multivitamin supplement or dehydration.
Hct (%) (42%-52%) 24.5 – 28.5 Improving gradually because of the
multivitamins supplement or dehydration.
In fact, the original decrease for Hgb &Hct
is related to inadequate oral food intake,
which increased nutrient need (acute
phase proteins, iron).
Na+ (mEq/L) 135-145 128 133 130 Improving gradually due to multivitamins supplement.
K+ (mEq/L) 3.6-5 3.7 4.1 4.4 Initial low due to dehydration. Overall the
all test result of K+ were within the normal
range.
Things to consider:
IM is a 68 YOBF whose BMI places her in the normal range, and although her BMI has become lower, due to the progression of her cancer, she is still in the normal range. The key is to stop any further loss of weight. IM also has a history of smoking and has type 2 diabetes. Those factors combined, with her age and gender, put her at a greater risk of developing cancer.
The nutrition problem list developed to create a nutrition care plan for IM ranked in the order of importance is as follows:
1. Malnutrition: due to her low food intake, and this will lead to progressive weight loss in a short
time. This is a common side effect of cancer cachexia. Other first side effects are anorexia, fatigue,early satiety, immunosuppression, and metabolic rate. This problem is ranked first on the list because cancer patients require adequate amounts of energy intake, protein, antioxidants, and those factors should be top priority for a registered dietitian (5).
Mucositis / Mouth soreness/ Difficulty swallowing:oral mucositis is a side effect of radiotherapy, which leads to increased difficulty when eating. To reduce soreness of mouth, an RD can monitor the food acidity and its temperature to make it easier for IM to eat. IM’s ability to consume food and liquids, to increase her fluid and energy intake, depends on her ability to swallow, and how comfortable she is with regards to eating. If IM is unable to eat, a feeding tube should be provided (5).
Type 2 Diabetes: as we suggested that the patient could be placed on an enteral feeding plan, if this suggestion is implemented the diabetic formulas should be used, as the patient has type 2 diabetes.
Dehydration and constipation:dehydration could be the cause of the constipation, and it results in low hemoglobin/hematacrit concentrations in the blood. In fact, constipation could cause nausea. Also dehydration leads to electrolyte and fluid imbalances (5).
Nausea and vomiting: secondary problem to radiotherapy and medications (5).An RD can monitor food tolerance, frequency of meals and size. Also, a physician may prescribe medication to decrease the synptoms.
Xerostomia: common side effect of radiotherapy (5), and less significant because fluid could be provided with food, such as soups.
Drug-Nutrient Interactions: having several medications, the patient needs to know if there are any possible drug-nutrient interactions, and how harmful they could be. The drugs described below did not involve any known drug-nutrient interactions, except for the multivitamin.
Low income and potentially minimal access to adequate healthy food, knowledge of food preparation: in the case of our patient, these items would not be our concern because she is getting her treatment at the hospital, and later on when she is feeling better and more alert we could discuss these issues with her.
Medication list:
Dilaudid syrup (Morphine): hydromorphone; a very potent centrally acting analgesic drug of the opioid class. Patient should avoid consuming alcohol to prevent constipation and diarrhea (1). Also, a side effect of dilaudid syrup is hyprecalcemia (2).
Colace: treatment for constipations (should be taken with a plenty of water; used as a stool softener). However, prolonged use may cause irritation of the gastrointestinal tract (3).
Sodium bicarbonate mouth rinse: The most commonly used mouth rinse, a natural buffer to the mouth’s PH that supports good oral health. In fact, this should help IM to improve her mouth soreness.
Mycostatin: polyene antifungal medication. Mycostatin is often given to patients at risk of fungal infections, including those under chemotherapy treatment. In addition, it could also lead to mouth irritation and diarrhea (4).
Multivitamins: contain different kind of formulas that are designed to meet micronutrient needs depending on the elemental forms of a variety of vitamins and minerals. These elemental forms may have an impact onIM’s recovery.
2. PES: The intake of energy and fluid is inadequate in relation to dehydration and stage 3 carcinoma of the mouth, and treatment side effects which lead to swallowing problems and mouth soreness as evidenced by low albumin, low hemoglobin, low hematocrit and low sodium outcomes from the laboratory tests. IM has a history of type 2 diabetes with no further information.
3. Nutrition care plan for IM.
Goals of nutrition care for IM.
1.To prevent nutrient deficiencies.
2.To preserve lean body mass.
3.To minimize nutrition and treatment-related side effects,such as decreased appetite/nausea.
4.To maximize her quality of life and to help her to survive (5).
IM will be in a hospital for almost a month and the gastronomy tube feeding(due to difficulty in swallowing) will be her first treatment to meet her daily caloric needs. When IM shows interest, food and beverages will be provided to encourage her oral eating and drinking, but considering IM’s current status it is crucial to increase the energy intake.
IM is advised to stop taking multivitamin, because the enteral formula will be sufficient to meet her micronutrient needs. Also, multivitamins may interfere with her recovery. Furthermore there is no need for her to take Colace because with the new enteral feeding plan the patient will meet her nutrient and fluid needs. Also, the best option is to wait until the patient’s bowel movements are re-evaluated. The other medications (sodium bicarbonate mouth rinse, and mycostatin) will be maintained, and evaluated except for the increased level of fluids neededdue to the effects of the Dilaudid Syrup.
IM also needs to be educated on good oral health and provided with oral hygiene care. In addition, if during the intervention our patient is not responding well to an enteral feed, expressed by high residual and risk aspiration, a parenteral feeding plan will be formed.
IM requires 1565.7 kcal/day and 2030 ml/day of fluid, as IM has carcinoma on her mouth, mucositis, and will be having 25 radiation treatments to the neck. Therefore, a nasogastric tube (NGT) will be avoided, to decrease the irritation of the cancer and treatment site. In fact, there is no indicator of the GI distress, so a gastronomy tube with polymeric solution should be used to maintain the GI health and function(5). Another problem we need to be aware of is IM’s type 2 diabetes. Therefore, the glucose control formula (Glucerna 1.5) will be used. The administration of the enteral formula will be 5 times a day at a rate of 359 ml of formula accompaniedby 112ml water, because the GI system of most patients can tolerate 500ml. Glucerna 1.5 cal formula contains, per 250 ml: protein, g: 19.6, fat, g: 17.8, carbohydrate, g: 31.5, dietary fiber, g:3.8 L-carnitine, mg:51, taurine, mg:40, m-inositol, mg:205, water, g:180, calories: 356. The energy and fluid requirements for IM will be met using this formula, because it contains sufficient amounts of protein, which will help stabilize her diabetes (6).
Calculations:
Estimated Energy(EE) needs for people with cancer: cancer, nutrition repletion, weight gain:
Daily energy requirements using Harris Benedict’s Equation are based on IM’s diagnosis, anticancer therapy, and metabolic complications. Stress factor for cancer patient is 1.1-1.3
EER=655.1+(9.563xwt)+(1.850xht)-(4.676xage) x stress factor
EER=655.1+(9.563×58)+(1.850×169)-(4.676×68) x 1.3
EER=655.1+554.6+312.6-317.9X1.3
EER=1522.3-317.9 X 1.3=1204.4 x 1.3= 1565.7 kcal/day
EER Range= 1324.84-1565.7 kcal/day
Protein: based on the degree of malnutrition, disease, stress, and ability to metabolize and use protein. IM needs 10%-35% of protein in her diet. Stress cancer patient: 1.5-2.5 g/kg/day (the higher end of this range will be used due to IM’s situation).
2.5 x 58 kg= 145g/day.
Protein energy malnutrition is the single most common secondary diagnosis in cancer patients (5). So, IM needs 90-100 g protein/day for maintenance and 100-200g protein/day for repletion.
Fat: the recommended level of fat is 20%-35% of energy.
Fluid:The upper level will be used as goal due to current hydration status and opioid medications. The recommendation for adults: 30-35ml/kg/day
58*30= 1740ml/day, 58*35= 2030ml/day.
Fluid received from enteral formula: 1795 ml
Fluid recommend from other source: 2030ml/day-1795ml/day=235ml/day
Fluid required with each feeding: (235ml/day)/5=47ml 5x/day (5)
The selected formula is Glucerna 1.5 formula:
Contains: 1.5kcal/ml, 1795ml/day required to meet energy requirements
Required formula at each feeding= (1795ml/day)/5=359ml 5 times/day (6)
4. An Assessment plan to monitor IM’s progress:
Dietary plan objectives:
Individualized nutrition intervention to ensure adequate nutrition intake and weight maintenance.
Consume a healthy diet that contains the recommended amounts of essential nutrients, including protein, carbohydrate, fat, vitamins, minerals, and water.
Consume sufficient amounts of energy and protein to maintain nutrition stores and to achieve and maintain a healthy lean body mass and BMI appropriate for height.
Adopt a physically active lifestyle (5).
Symptoms such as loss of appetite, nausea, vomiting, weight change, changes in taste and smell, pain, fatigue, and disturbances of the gastrointestinal tract (GIT) are common side effects of cancer treatment and can lead to inadequate nutrient intake and subsequent malnutrition. In most cases, eating enough foods rich in vitamins, anti-oxidants, calories and protein can prevent malnutrition. These include fruits and vegetables, whole grain products, lean cuts of meat, and whole-fat dairy products (5).
Several support staff will be required to assist IM’s recovery. These will include a speech therapist, a primary oncologist, multiple nurses, a social worker, a dietitian and a variety of lab technicians. IM’s health status will be monitored regularly for factors including alertness, wasting, and complexion. Also, her fluid intake and output will be monitored daily to ensure that she is meeting her energy and fluid needs, and her weight will be measured 3-5 times a week. In addition, it is important to monitor the hydration daily, and electrolytes will be tested in the laboratory on a weekly basis. Based on her weight status, her nutritional adequacy will be re-evaluated and intake will be monitored twice weekly. BUN and creatinine levels will be monitored weekly.
In addition, it is better to monitor gastric residuals before each additional feeding, and record these evaluations to ensure she is maintaining tolerance. If excessive residuals are persistent for more than 2 consecutive feedings, then the bolus rate will be re-evaluated and lowered. To control type 2 Diabetes, hydration status, and wasting, the levels of albumin, serum glucose, Hct, and Hbg will be monitored weekly. If the nutritional status has improved then albumin status will be improved, related to the evidence that albumin can be used as indicator of morbidity, and so it will be monitored weekly (7).
Since the patient is receiving radiotherapy and has been taken off of Colace, her bowel movements will be monitored daily to ensure regularity and the absence of constipation or diarrhea. It is also crucial to monitor IM’s oral health to ensure that current food choices and feeding options are still relevant. In the end, the client and her family members should be evaluated to ensure that they understand the principles of food safety prior to discharge.
5. Prepare a chart note (using ADIME format) detailing your plan for IM.
Assessment:
Pt. is 68 YOWF admitted with stage 3 carcinoma on floor of the mouth
Normal Ht.:169 cm Normal Wt.: 62 kg Current Wt.: 58 kg
Estimated Wt. Loss: – 4kg
BMI (current) 20.3, and BMI (usual) 21.7. Both are normal.
Laboratory results indicate low and decreasing albumin.
Laboratory value noted:
Albumin(g/L) Hbg (g/L) Hct(%) Na+(mEq/L) K+(mEq/L)
07/29 34 84 24.5 128 3.7
08/31 33 – – 133 4.1
09/12 29 97 28.5 130 4.4
EER:1565.7 kcal/day, depending on current weight, cancer and also the desire to gain more weight.
Fluid requirements: 1740-2030ml/day
Protein requirement: 145g/day
IM is eating~550 kcal/day (without consider the discard food, and over estimation).
Previous smoker.
Unknown dietary history.
On multiple medications: Dilaudid syrup, Colace, multivitamin, mycostatin, and sodium bicarbonate mouth rainse.
Experiencing mouth soreness, and difficulty swallowing.
Disordered cognition
The presence of worsening mucositis (09/07)
Undergoing radiotherapy (25 sessions) 09/03-10/04
Patient has type 2 Diabetes (IM may have previously taken unknown medication but is not on insulin).
Diagnosis:
Increased caloric needs related to the presence of tumor from carcinoma.
Progressive wasting due to malnutrition, related to increased nutrition requirements for total energy, protein, fat and carbohydrate.
IM has increased protein catabolism as evidenced by the decreasing level of serum albumin.
Energy intake is inadequate, evidenced by caloric count of`550kcal/day and weight loss of 4kg.
IM is exhibiting dehydration as evidenced by low sodium levels, very high HBG, mucositis, difficulty swallowing, and very low Hct.
Intervention:
Immediate EN (gastronomy enteral nutrition) plan – (PEG tube) of Glucerna 1.5cal as a bolus 5 times a day: 359ml Glucerna 1.5cal and 112ml water per feeding to meet IM fluid and energy need.
Remove multivitamin and Colace medication.
Applied swallowing test.
Determine current diabetes management and use glucose control formula.
Educate patient and her family about good oral hygiene, risk factors related to poor diet, food safety, and proper diet prior to discharge.
Goals to reach:
Suppress tumor growth.
Limit patient discomfort.
Patient will progress from PEG feeding to oral feeding.
Adequate intake of energy and fluids.
Control the level of blood glucose (type 2 diabetes) without adding any medication.
Increase patient’s body weight and minimize wasting.
Monitoring:
Weight: 3-5 per week.
Fluid input and output: daily.
Gastric residual: before each feeding (5 times daily).
Bowel movements: daily.
Albumin, serum glucose, Hbg, Hct, BUN, creatinine: weekly.
Mouth soreness: daily.
Ability to swallow: weekly.
Hydration: daily.
Electrolytes, Na+, K+, Calcium: weekly.
PEG tolerance: daily.
Nutrition intake calories and adequacy: 2x/week.
Evaluation:
Determine need for Colace, and anticipate weight gain until IM returns to her normalweight, as well as possible improvements in serum albumin, Hbg, Hct, NA+, K+, and blood glucose.
Also, determine if the patient is able to consume foods and beveragesorally without any problem.
6. Prepare IM for discharge and follow-up: When IM completes her treatment she and her daughter will be educated on how to follow a healthful diet with regards to IM’s condition prior to her discharge. During that time they will also be informed of the risks of consuming an unhealthful diet, and smoking in relation to the potential reoccurrence of cancer. Since IM has difficulty listening to instructions, she will be also given dietary instructions in written form. Furthermore, it is suggested that she follow up with a dietitian within 2 weeks of discharge so that her dietary intake can be monitored and so she can be given encouragement to follow a healthful diet.Finally, establish slow, steady weight gain and physical activity goals for the next three months, by reporting the importance of physical activity in rebuild muscles, regain strength and energy. Exercise also stimulates appetite, improves mood, reduces side effects such as nausea and constipation (5).
References:
Drugs.com.2013. “Drugs information online: Dilaudid syrup” Last modified Oct 2013 http://www.drugs.com/disease-interactions/guaifenesin-hydromorphone,dilaudid-cough-syrup.html. Accessed Oct 30 2013.
Purdue Pharma. 2008. “Monograph: Dilaudid”. Last modified April 28 http://www.hc-sc.gc.ca/dhp-mps/prodpharma/databasdon/index-eng.php2011 Accessed Oct 30 2013.
Drugs.com.2013. “Drugs information online: Colace” Last modified Oct 2013 http://www.drugs.com/cdi/colace.html. Accessed Oct 29 2013.
Drugs.com.2013. “Drugs information online: Mycostatin” Last modified Oct 2013
http://www.drugs.com/cdi/mycostatin.html. Accessed Oct 29 2013.
Mahan K, Escott-Stump S, Raymond J. Krause’s food and the nutrition care process, 13th ED. Elsevier Saundres. Missouri. 2012.
Abbott Nutrition. 2013. “Glucerna 1.5 cal” Last modified n.d.http://abbottnutrition.com/brands/products/glucerna-1_5-cal. Accessed Oct 30 2013.
Fuhrman MP, Charney P, Muller CM. Hepatic protein and nutrition assessment. J Am Diet Assoc. 2004 08;104(8);1258-64.
