Clinical


M A J O R   C A S E   S T U D Y


Medical Nutrition Therapy in a Cachectic Patient with Metastatic Cancer

Below, you will find an outline of the nutrition assessment I completed for my major case study. I chose a patient with metastatic prostate cancer. To see the details of my report (executive summary, case report, hospital summary, medical considerations, nutritional therapy, research, labs, medications) please check out the attached PDF: Medical Nutrition Therapy in Cachectic a Patient with Metastatic Cancer.

Nutrition Assessment: 12/6/17
Age: 67 years old

Gender: Male

Weight: 50 kg (110 lbs)

UBW: 190 lbs

% UBW Weight loss: 80 pounds (42%)

IBW:

Height: 6’ 8” (80 in)

BMI: 12.10 (underweight)

PMH: Possible cardiomyopathy with ejection fraction of 10% (1998) with repeat EF of 55-60% on 12/6/18; AFib; hyperthyroidism; alcoholism; remote cocaine abuse; HTN; goiter; frostbite requiring amputation of 2-4th digits on right hand; arthritis

Symptoms: Weakness PTA, reported 80# wt loss over 6 months 

Diet History:Variable intake pta due to limited access to food and weakness. Family members (most often sister) help with groceries and cooking when available. Meals on Wheels Monday-Friday. Patient claims milk upsets stomach. Poor dentition, but pt states this does not limit his ability to eat.

Weight History:80# weight loss over past 6 months

Labs (admission 12/5):

Na: 143
K: 3.6 (L)

Cl: 105

Cr: 0.8

Glucose: 96
BUN: 15

Mg: 1.9

WBC 6.8

12/6:

Phos: 2.7

Mg: 1.6

Medications prior to admission: unknown

Current medications:

Pepcid

Heparin

Ampicillin

Azithromycin

Current Diet: Regular (no milk)

Nutrition Diagnosis
Inadequate oral intake (NI-2.1) related to limited access to food and difficulty preparing food as evidenced by patient/family reports ~80# weight loss, weakness, assistance with meals by family and Meals on Wheels.

 Malnutrition related to inadequate caloric and protein intake and significant muscle wasting as evidenced by patient consuming <75% of EEE for >7 days, severe muscle wasting to shoulder, clavicle, temporal, buccal, calf, and thigh with severe subcutaneous fat wasting to orbital fat pad, tricep and ribs. 

Underweight (NC3.1) related to suspected poor oral intake as evidenced by BMI of 12.10 and 42% wt loss in past 6 months.

 Increased nutrient needs (NI-5.1) related to hypermetabolic state as evidenced by prostate cancer metastatic to bone, liver, lung, pelvis.

Nutrition Intervention
Nutrition Prescription
Using Facility Standards: 50 kgCalories: 2250 kcal per day using 45 kcal/kgProtein: 100 g per day using 2 g/kgFluids: 1500g per day using RDA

Regular consistency

Intervention with goals
Prescription medication (ND-6.1):
Recommend appetite stimulant of Marinol. GOAL: Patient’s PO intake improves.Collaboration with other providers (RC 1.4): Ask for patient to be given Lactaid pills to improve tolerance of milkshake supplements and stress the importance of nutrition for this patient with a hx of 80# weight loss and malnutrition. GOAL: Patient receives Lactaid pills and is able to consume milkshakes without GI upset/ diarrhea.Survival information (E-1.3): explaining pt’s already increased needs to maintain natural body weight as well as additional energy needs because of his cachectic state. GOAL: Patient’s PO intake improves, and weight eventually begins to increase.Referral to other providers (RC-1.5): Refer to outpatient oncology RD. GOAL: Patient receives more information regarding cancer and nutrition, and nutritional status is monitored after discharge.
Nutrition Monitoring and Evaluation
Indicators

1.     Nutrition related labs (BD-1.2, 1.5)

2.     Total energy intake (FH-1.1.1.1)

3.     Liquid meal replacement or supplement (FH-1.2.1.3)

4.     Food and nutrition knowledge (FH-3.1)

5.     Adherence (FH-4.1)

6.     Weight (AD-1.1.2)

 

 

Criteria

1.     Normal levels of electrolytes from blood drawings

2.     Patient consumes >75% of meals.

3.     Patient consumes >75% of nutrition supplements.

4.     Patient is able to describe the importance of optimal nutrition during cancer.

5.     Patient visits outpatient oncologist (and oncology RD if possible) and follows diet recommendations after discharge.

6.     Patient’s weight trends increase.


I N T E N S I V E   C A R E   U N I T


The Intensive Care Unit (ICU) is a constantly moving machine of health professions working 24/7 to treat patients in critical care. The interdisciplinary team (IDT) is a major part of this unit.  Health professionals work together to solve challenging cases by sharing information, asking question, and discussing options of care. Check out my blog on the IDT! Teamwork Makes the Dream Work: The Interdisciplinary Team Approach.


W O U N D   H E A L I N G 


Wound Healing Infographic

I created this infographic to highlight the most important factors to be considered for wound healing. I was inspired to create this after my preceptor discovered that a patient’s wound dehisced due to steroids. The patient had been receiving adequate protein for a week, which raised the concern of why the wound was not healing at all. Once we realized that the patient was on steroids, we spoke with the intensivist who discontinued the steroid.