Memorial Case Study Ashley Edwards D
Memorial Case Study Ashley Edwards D
Memorial Case Study Ashley Edwards D
Study
Ashley Edwards
Outline
Medical Medical
Assessment PMH Diagnose Nutrition Prognosis
s Therapy
Assessment
99% IBW
59 YO Male 129lbs / 58.6kg
BMI 22.0
Date
Unit: 2C Surgical
64 inches Admitted:12/4/19
ICU
HYPERTENSION
CONSTIPATION
HYPERCHOLESTEROLEMIA
Past
Medical
FORMER DRINKER: 6-8 BEERS/DAY History
Nutrition:
• NPO - trach
• Pt cleared to start TF POD2
Oral Cancer
Risks:
https://oralcancerfoundation.org/understanding/tobacco/
Gorenc, M., Kozjek, N. R., Strogan, P. (2015). Malnutrition and cachexia in patients with head and neck cancer treated with (chemo)radiotherapy. Reports of Practical Oncology and
Radiotherapy, 20(4), 249 – 258. https://doi.org/10.1016/j.rpor.2015.03.001
Oral Cancer
Complications
• Dysphagia and xerostomia
• Symptoms related to the tumor
• Mechanical obstruction, dysphagia, odynophagia, & anorexia
• Tumor-specific therapy
• N/V/D
• Changes in the taste
• Extraction of unhealthy teeth before radiotherapy
• Opioid-induced GI dysfunction
• Surgery:
• Remove tissues, lymph nodes in neck often also removed
https://oralcancerfoundation.org/understanding/tobacco/
Gorenc, M., Kozjek, N. R., Strogan, P. (2015). Malnutrition and cachexia in patients with head and neck cancer treated with (chemo)radiotherapy. Reports of Practical Oncology and
Radiotherapy, 20(4), 249 – 258. https://doi.org/10.1016/j.rpor.2015.03.001
Dry Mouth (Xerostomia)/Sore
Throat/Mouth
• Increase fluids
• Moist, soft foods, lukewarm foods with gravies
Head and Taste Changes
Neck • Plastic utensils
• Use seasonings
Cancer
Poor Appetite & N/V
MNT • Eat small meals or snacks every 1-2 hrs
• Avoid liquids with meals
• Eat dry foods (crackers/toast)
• High calorie, high protein snacks on hand
Associated with poor prognoses
WL important predictor of mortality
Especially prevalent in GI cancers
MALNUTRITIO affects >80% of cancer patients with
N IN CANCER upper GI cancers
50-70% experience significant WL before
PATIENTS prognosis
20-40% of cancer patients die from the
effects of malnutrition and its complication,
rather than from the cancer itself
Hark, L., Deen, D., & Morrison, G. (2014). Medical nutrition & disease: A case-based approach (5th ed.). Chichester, West Sussex, UK: Wiley Blackwell.
Gorenc, M., Kozjek, N. R., Strogan, P. (2015). Malnutrition and cachexia in patients with head and neck cancer treated with (chemo)radiotherapy. Reports of
Practical Oncology and Radiotherapy, 20(4), 249 – 258. https://doi.org/10.1016/j.rpor.2015.03.001
Cancer Cachexia
Refractory
Pre-Cachexia Cachexia Cachexia
• Early metabolic signs such as • Ongoing loss of skeletal • Advanced cancer or pre-
• loss of appetite muscle mass (with or w/o terminal
loss of fat mass
• impaired glucose • Rapidly progressive
intolerance
• Cannot be fully reversed
cancer
through conventional
• involuntary weight loss nutrition support • Presence of factors
of 5%
• 50% experience sarcopenia making management no
• Dependent on: longer possible or
• Characterized by:
• Type appropriate
• Weight loss > 5% OR
• Stage • Life expectancy of less
• BMI < 20 w/ WL >2% than 3 months
• Inflammation
OR
• Response to therapy
• Sarcopenia & WL >2%
Initial Nutrition Assessment: 12/5
Info From Patient and Wife
RD consult for TF Recs
• Pt difficulty eating and High Nutrition
• <50% usual intake >/= 1 month Risk Screening
• WL: 6.8 kg (10%) in 3 months
• Severe Chronic Malnutrition Dx
Labs: Reminder:
• Glucose High (159) • Admit Weight: 58.6
• Phos Low (2.1) • 99% IBW
• BMI = 22.0
Additional Info
• Pt had dental extraction as advised before starting
radiation
• Keofed Nasogastric tube for meds only
Initial Assessment MNT: Thursday 12/5
Est. Nutritional Needs:
• 1760 – 2005 kcal (30-35 kcal/kg for Cancer/Wt Gain)
• 73 – 88 gm PRO (1.25-1.5 gm/kg IBW)
Nutrition Plan:
• Continue current nutrition plan
Medications
Cardiovascular Meds
• Amlodipine- HTN
• Ramipril (Altase) – HTN
• Heparin – Blood thinner
• Simvastatin – cholesterol
Surgery
• Propofol
• Phenylephrine – vasopressor
• Hydrocodone
• Hydromorphine
• Fentanyl
• Rocuronium – Muscle relaxant
• Sugammadex – reversal of neuromuscular blockage induced by rocuronium
• Decadron – Steroid/anti-inflammatory
Replete
• Thiamine
• Magnesium sulfate
• MVI with Minerals
Assessment
• TF to start today
• Lactated ringers and potassium phosphate
infusing during visit.
• Pt down 1.5 kg since admission, but
experiencing negative fluid balance
• Pt received Mg Sulfate 12/5
Follow-up Labs
MNT
Positives
• Lytes WNL Weight Hx:
• Weight stable - Admit Weight: 58.6 kg
- Current weight: 59.5 KG
MNT:
• Continue to monitor TF tolerance • Watch Lytes
• Monitor BM, GI function • F/U Thursday
Prognosis
Medical
Anticipated D/C 12/12 – 12/14
D/C home with Home Health & DME
Radiation?
Nutrition
SLP to evaluate today
G-tube placement TBD
Gastrographic esophagram today
Conclusion:
EAL: • 7 studies with 1.2 – 2.2 g EPA per day resulted in
improvement or preservation of LBM
• 2 studies showed same effect, but not sat. sig.
Medical food
• More research needed to determine optimal dose
supplements
(MFS)
containing fish Grade: I
oil on lean body
mass (LBM) in • Grade I means there is Good/Strong evidence
supporting the statement
adult oncology
patients
Additional studies agree: See handout
Tried to figure out what is happening long
What I would term with TF
have done
Can do at F/U on Thursday
Will he eat orally soon?
differently
QUESTIONS?
References
https://oralcancerfoundation.org/understanding/tobacco/
Gorenc, M., Kozjek, N. R., Strogan, P. (2015). Malnutrition and cachexia in patients with
head and neck cancer treated with (chemo)radiotherapy. Reports of Practical Oncology
and Radiotherapy, 20(4), 249 – 258. https://doi.org/10.1016/j.rpor.2015.03.001
Hark, L., Deen, D., & Morrison, G. (2014). Medical nutrition & disease: A case-based approach (5th ed.).
Chichester, West Sussex, UK: Wiley Blackwell.
Gorenc, M., Kozjek, N. R., Strogan, P. (2015). Malnutrition and cachexia in patients with
head and neck cancer treated with (chemo)radiotherapy. Reports of Practical Oncology
and Radiotherapy, 20(4), 249 – 258. https://doi.org/10.1016/j.rpor.2015.03.001
Head and neck cancer nutrition therapy. Nutrition Care Manual.
https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=135