Meet B.G.
A NUTRITION CARE PLAN BY MICHELLE SARTA
B.G.
B.G.
65 yof who presented to ED on 3/21/18
reporting SOB x 4d. MD admit dx acute
respiratory failure related to COPD
Currently has non-small cell lung cancer
(NSCLC)
Hx of colon and uterine cancer
Severely malnourished
Supportive husband
Lung Cancer & COPD
Cancer abnormal, dysregulated
cell growth throughout the body
NSCLC makes up majority of lung cancers
Poor 5-year survival rate (16%)
COPD Chronic bronchitis
coupled with emphysema
Ind. RF for lung cancer
Thought to be attributed to chronic
inflammation and MDSC expansion
Other RF
Smoking (1 PPD x 45 years)
Genetics
Anthropometrics
Ht: 5’1 61” (154.9 cm)
Wt: 87 lbs 39.5 Kg
IBW: 105 lbs (47.6 Kg)
%IBW: 82.85%
UBW: 147 lbs (66.7 Kg)
%UBW: 59.22%
BMI: 16.45 kg/m2 Underweight
Hx of weight changes
12/3/17 1/17/18 1/18/18 3/10/18 3/21/18 3/26/18
66.7 Kg 63.5 Kg 50.8 Kg 55 Kg 44 Kg 39.5 Kg
147 lbs 139 lbs 112 lbs 121 lbs 97 lbs 87 lbs
Involuntary wt. loss of:
27.2 Kg (~60 lbs) in ~4 months (-40%)
15.5 Kg (34.1 lbs) in previous 16 days (-28%)
Medications
Drug Purpose Side Effects Nutr. Concerns
Atorvastatin Antihyperlipidemic N, D, dyspepsia, abd. pain, constipation, Caution w/ grapefruit/related
flatulence, edema. citrus
Fluoxetine Antidepressant Anorexia, dry mouth, dyspepsia, N/V/D ↑ anorexia in geriatric pop.
(Prozac) Avoid alcohol & tryptophan
suppl.
Megestrol Appetite Stimulant ↑ appetite / wt. Edema. ↑ serum Na+ Take w/ high fat meal
Olanzapine Antipsychotic (BPD) ↑ appetite & wt., dry mouth, dyspepsia, Hypoalbuminemia may ↑ drug
constipation. ↑ glucose & TAG. effects.
Additional Meds:
Wound protocol for stage I pressure ulcer: Vit C, MVI, Zinc
Vitamin D, laxative, antigerd, antianxiety, anticoagulant, orthostatic HTN
Abnormal Labs (Biochemical Data)
Lab Normal BG’s Date Interpretation
Range value
Anion Gap 7-17 8 (12) 3/26 WNL, but sig. drop within 2 days
(3/24)
Glucose 65-99 mg/dL 118 3/26 H – may be medication side effect (Olanzapine)
(106, (previou
134, s3
145) dates)
BUN 8-21 mg/dL 6 3/26 L – lack of protein intake
TSH 0.27-4.2 miu/L 5.83 3/24 H – related to disease of thyroid gland
Hgb 11.7-15.7 10.6 3/26 L – cancer and/or iron-def anemia
g/dL
Hct 35-47% 33 3/24 L – May be RT cancer / malnutrition
Abs. 1.5-4.5 K/uL 0.98 3/24 L – WBC used by immune sys. Lower in cancer.
Lymphocyt
es
RBC 4-5.4 m/uL 3.66 3/24 L – anemia, inadequate intake and/or cancer
NFPE
Evident muscle loss /wasting
Temporalis
Orbital
Interosseous
Pectoralis & Deltoid
No appetite
Tired, irritated
Complained of feeling cold
Estimated Needs & Current intake
Kcals: Mifflin-St. Jeor: ~1,350 kcal/d
1.3 SF (malnourished)
Protein: Cancer Cachexia: 1.5-2.5 g/kg
~60 – 100 g/d
Fluid: 30 ml/kg (39.5)
1,185 mL/d
Current diet order: Regular
Minimal to no PO intake
Drinking ginger ale & sips of water
Some IV fluid intake
Refusal of PO supplements
Malnutrition (chronic severe PCM) RT cancer cachexia
PES and patient refusal of PO intake AEB unplanned weight
loss of 27.2 kg (40%) in ~4 months and severe loss of
Statement: muscle mass (wasting of temples, clavicle region, and
interosseous muscles) and subcutaneous fat loss
Diagnosis (orbital region).
Intervention / Goals
Rec nocturnal EN support over 12’. Start 6pm day 1 @ 35 mL/’ x 12’
and off. Day 2; 1st hour @ 35 mL/’ then adv. to 80 mL/’ x 10’ (7pm –
5am) and final rate decrease to 35 mL/’ and off at 6am with 175
mL flushes Q4. Total volume 1,395 mL (870 mL formula + 525 mL
water), providing 1,300 kcal, 81.6 g protein, 44.2 g fat, 148.2 g CHO,
6.5 g fiber, and 1,185 mL fluid. PO for recreation, following PO
intake, labs (K, P, Mg), and pt tolerance. Adjust PRN.
BG will tolerate at least 80% of total TF daily
BG will continue to be offered palatable meals throughout the day
PO for recreation
BG will continue to be encouraged to try PO supplements
Monitoring & Evaluation
BG will be monitored for tolerance to tube feed, goal of >80%
daily. K, P, & Mg will be monitored, and BG will be watched for
refeeding syndrome
BG’s PO intake will be monitored, and tube feed requirements
will be adjusted PRN
BG’s weight status will be monitored; BG will not lose any more
weight, and will gain in an upward trend
0.5-1 lb/wk
F/U with repeated NFPE in order to track progression / regression
in muscle mass and subcutaneous fat mass
Thank You for Listening
Any Questions?
References
Escott-Stump S. Nutrition and diagnosis-related care. Philadelphia: Wolters Kluwer; 2015.
Mahan LK, Raymond JL. Krause’s food & the nutrition care process. 14th ed. St. Louis, MO: Elsevier; 2017.
Pronsky ZM, Elbe D, Ayoob K. Food Medication Interactions. 18th ed. Birchrunville, PA. 2015.
Daily Value Reference of the Dietary Supplement Label Database (DSLD). (n.d.). Retrieved April 1, 2018, from
[Link]
Nutrition Care Manual. (n.d.). Retrieved April 2, 2018, from [Link]
Immunotherapy. (n.d.). Retrieved April 05, 2018, from [Link]
cancer/treatment/types/immunotherapy
Scrimini, S., Pons, J., & Sauleda, J. (n.d.). The role of myeloid-derived suppressor cells in the relationship between
chronic obstructive pulmonary disease and lung cancer. Retrieved April 10, 2018, from
[Link]
[Link]
