The patient, a 58-year-old male smoker and drinker, was diagnosed with stage II adenocarcinoma of the esophagus based on biopsy following tests. He underwent an esophagectomy and jejunostomy tube placement, with plans for post-operative radiation. He experienced significant unintended weight loss and nutritional deficiencies. His nutrition care plan focused on transitioning from TPN to tube feeding using an elemental formula, monitoring hydration and biochemical parameters, and providing education on appropriate medical nutrition therapy to meet his needs during and after cancer treatment.
1. Esophageal Cancer Treated with Surgery and Radiation
FSHN 450
Carolina chaves
“I HAVE NOT GIVEN, RECEIVED OR USED ANY UNAUTHORIZED ASSISTANCE
ON THIS ASSIGNMENT”
Carolina Chaves
November 20 2015
3. FSHN 450
Fall 2015
Nick S. is a 58 year old male seeking medical attention for recurrent heartburn of 1 year
duration. He presented with difficulty swallowing for past 4 – 5 months and unexplained weight
loss
Education: College degree
Occupation: Contractor
Social Hx: Married, wife age 52, son age 17 in high school, daughter 19 away at college.
Smokes 20 cigarettes/day for past 40 years. Drinks 2 beers per day.
Medical Hx: States that “food gets stuck in throat”. Takes TUMS and Pepcid consistently for the
past year. Wt loss of 30 pounds past 3 – 4 months. Patient states he has been unable to eat
because of heartburn and difficulty swallowing, especially anything with course or crunchy
texture.
Physical Exam: thin, pale white male. Temp 98.3, BP 132/90, HR 88 bpm, RR 13 bpm, Ht:
6’3” UBW: 220 # CBW: 190 #
HEENT: eyes sunken, sclera clear, dry mucous membranes
Skin: warm, dry
Chest/lungs: cleat to auscultation and percussion
Abdomen: epigastric tenderness
Nutrition Hx:
Appetite general poor PTA. Regurgitation of some foods, reports pain upon swallowing
Usual Dietary Intake:
AM: eggs, toast, coffee with 2 tsp sugar (but no longer drinks coffee with heartburn)
Lunch: cold sandwich packed for worksite (3 oz meat, two slices white bread). Lately c/o bread
sticks in the throat – 24 hour recall notes only tomato soup and 4 crackers
Dinner: Generally eats all meats, vegetables, potato or rice but 24 hour recall notes only baked
macaroni and cheese and 1 scoop vanilla ice cream
Evening: Two beers (but has contributed to heartburn so has mostly cut out beer lately)
Food purchased and prepared by wife.
Food allergies: NKA
4. Dx: Diagnosis following X-ray, endoscopy and biopsy – Stage II (T1,N1,M0) adenocarcinoma
of the esophagus
See admission laboratory report (attached)
Tx Plan: Transhiatal esophageal esophagectomy. Jejunal tube placed for later feeding.
Radiation planned post-operatively.
Rx: NPO with TPN post-operatively progressing to tube feeding as tolerated.
Case report:
NORMAL ADMIT
9/5
9/11 REASON FOR VARIANCE: UNITS
Albumin 3.5 – 5 3.1 3.0 ↓ Malnutrition, low protein intake, cancer. g/dL
Total
protein
6.3-8.2 5.7 5.7 ↓ Protein deficiency. g/dL
prealbumin 16-35 15 12 ↓malnutrition, surgery, low protein intake. mg/dL
Transferrin
admit
Transferrin
9/11
215-365 285
175
Normal
↓ cancer, malnutrition
mg/dL
Sodium 136-145 137 136 Normal mEq/L
Potassium 3.5-5.5 3.8 3.6 Normal mEq/L
Chloride 95-105 101 99 Normal mEq/L
PO4 2.3-4.7 3.1 2.9 Normal mg/dL
Magnesium 1.8-3 1.8 1.8 Normal mg/dL
Total CO2 23-30 26 25 Normal mEq/L
Glucose 70-110 71 108 Normal mg/dL
BUN 8-18 9 10 Normal mg/dL
Creatinine 0.6-1.2 0.7 0.9 Normal mg/dL
Uric acid 4.0-9.0 6.2 Normal mg/dL
Calcium 9-11 9.1 9.4 Normal mg/dL
Bilirubin <3.0 0.2 0.3 Normal mg/dL
NH3 9-33 11 21 Normal µmol/L
ALT 4-36 21 33 Normal U/L
AST 0-35 32 27 Normal U/L
Alk phos 30-120 101 99 Normal U/L
CPK admit
CPK 9/11
20-200 172 145 Normal U/L
LDH 208-378 350 342 Normal U/L
Chol 120-199 180 170 Normal mg/dL
HDL >45 47 Normal mg/dL
LDL <130 129 Normal mg/dL
TG 40-160 158 Normal mg/dL
5. WBC 4.8-11.8 5.2 6.9 Normal X10^3
/mm^3
RBC 4.5-6.2 4.2 4.3 ↓ Anemia, Fe deficiency. X10^6
/mm^3
HGB 14-17 13.5 13.9 ↓ Anemia. g/dL
HCT 41-55 38 38 ↓ Blood loss, anemia. %
MCV 80-96 90 86 Normal µm^3
RETIC 0.8-2.8 0.9 1.0 Normal %
MCH 26-33 32.4 32.3 Normal pg
MCHC 32-37 35.5 36.5 Normal g/dL
RDW 11.6-
16.5
11.9 12.1 Normal %
Plt Ct 140-440 250 232 Normal X10^3
/mm^3
ESR 0-15 17 15 Normal mm/hr
%GRANS 34.6-
79.2
75 65 Normal %
% LYM 19.6-
52.7
25 35 Normal %
SEGS 50-62 55 60 Normal %
BANDS 3-6 4 3 Normal %
LYMPHS 24-44 28 32 Normal %
MONOS 4-8 4 5 Normal %
EOS 0.5-4 0.5 0.6 Normal %
Ferritin 20-300 220 208 Normal mg/mL
PT 11-16 12 12.8 Normal sec
1. What does the term adenocarcinoma mean?
- A type of carcinoma which tissue of origin are the glandular epithelium /connective tissue or
muscle.
2. What are the two most common risk factors for esophageal cancer? Does the
patient have these risk factor?
- Alcohol consumption: daily consumption of 2 -3 drinks increases risk 2 -3 times
compared with no drinkers.
- Tobacco and
- Obesity increase chances of developing cancer.
- The patient is a combination of all risk factors. As he smokes 20 cigarettes/day, had two
beers every day although lately he has cut out the beer and his usual BMI was 27.7 which
categorize him as overweight. Due to esophageal cancer he has lost weight and his current
BMI is 23.8 which put him in the recommended category decreasing risk of further obesity
related disease or slow recovery.
3. The patient’s stage was TII. What is the meaning of the terms T1, N1, M0?
- Cancer stages I, II, III, and IV. (I least amount of disease.)
- T stands for size of the tumor. TI = Small size tumor. Localized.
6. - N stands for nodes or whether it has spread into lymph nodes. NI = lymph nodes are
affected minimal by the cancer. Involvement of one set of lymph nodes.
- M stands for metastasis or whether the cancer has spread to distant organs. M0 = no
cancer has spread to distant organs.
4. Why is cancer therapy multi-modality?
- Treatment of cancer therapy is multimodality because it involve a combination of
different treatments like surgery, radiation, chemotherapy, biotherapy/immunotherapy to
accomplish various functions such as decrease tumor resistance, be more effectives,
decrease side effects and attach at different stage of cell division.
5. Evaluate the patient’s usual body weight and current body weight and risk factors
for malnutrition.
- Patient current body weight: 86.3 kg -> BMI: 23.8
- Patient usual body weight: 100 kg -> BMI: 27.7
- Total unintended weight loss: 13.7 kg in 3-4 months or
- A severe weight loss of 13.6% which is indicative of nutritional risk.
- The risk factors for malnutrition are: heartburn, dysphagia, and odynophagia,
regurgitation of some foods and loss of appetite which all contribute to decrease intake of
calories/day.
6. Assess the patients Kcal and protein needs for TPN. You do not need to calculate a
TPN but suggest a protein sources and % Kcal from protein, fat and glucose.
Kcal: 1.5 kcal x BEE
Harris benedict equation = BEE of 1810 kcal x 1.5 kcal = 2715 kcal or 31 kcal/kg which
is needed as the patient is malnourished.
Protein: 1.6g/kg = 138 g
20% of fat = 543 kcal
10% of protein = 552 kcal
70 % of glucose = 1620 kcal
Component Concentration Goal Volume (ml) Kcal
Protein 10% 1.6 x 86.3 =
138 g
10/100= 138/x
X= 1380
138 x 4 = 552
Fat 20% 543 g 2/1= 543/x
X = 271.5
0.2 x 2715 =
543
CHO 70% 2715 kcal –
(552 + 543) =
1620 kcal
70/100 =
1620/x
X= 2314 /3.4
kcal /g= 681
1620
Total 2715 kcal
7. Describe how you will transition the patient from TPN to tube feeding. Suggest a
product that you will use for tube feeding that will meet the need of this patient a) in
the post-operative period and 2) long term.
- To begin the transition from TPN to tube feeding I will introduce a minimal amount of
enteral feeding at a low rate of 40 mL/hr to see the gastrointestinal tolerance of the
patient. Once formula have been given during a period of hours I will decreased the TPN
rate to keep the nutrients levels at the same prescribed amount. I will increase the tube
feeding rate by 30 ml/hr every 24 hours and reduce the parental prescription accordingly.
7. The patient will be discontinued from TPN once he can tolerate 75 % of nutrient needs by
tube feeding.
- The product that I will use for tube feeding is calorie dense formula – Isosource HN 1.5
CAL designed for individuals with increased calorie needs and/or limited fluid tolerance
in the post-operative period. After establishing the tube feed for long term I will
recommend a standard formula like ensure which will increase fluid intake of the patient
as it is 85 % water compare to the calorie dense formula used in the post-operative which
is only 75% water.
8. Describe the volume and method of administration of the TF you selected for a)
post-operative recovery in the hospital and b) TF you selected for home (long term).
-post-operative recovery: the administration method will be continuous drip as the patient
don’t tolerate large volume of infusions during a giving feeding. The volume will be
75ml/hr in a 24 hour period which will provide 2700 kcal/day.
-tube feeding for home administration method will be intermittent drip. The schedule
will be six feedings per day administrated for 20-60 min. the formula administration will
be initiated at 150 ml per feeding and increased incrementally as tolerated by patient.
9. Compare fluid requirements to the amount of fluid provided in each tube feeding.
How will you make up the difference?
Fluid requirements: 30-40 mL/kg/day or 1 ml/kcal or 2589 mL /day
Fluid in Isosource 1.5 CAL = 0.75 ml/ kcal
Ensure 0.85 ml / kcal
I will make up the difference by administrating the patient with IV fluid hydration to
meer treatment related fluid needs.
10. Write a PES statement for the patients discharge plan including goals and follow –
up (list at least four factors you should monitor).
Nutrition assessment:
Client history:
Personal history: Nick is a 58 year old male, with a college degree and its current
occupation is contractor.
Medical history: for the past year patient have recurrent heartburn, States that “food gets
stuck in throat”, difficulty to swallow (dysphagia). Patient diagnosed with Stage II
(T1,N1,M0) adenocarcinoma of the esophagus
Social history: Married, wife age 52, son age 17 in high school, daughter 19 away at
college. Smokes 20 cigarettes/day for past 40 years. Drinks 2 beers per day.
Medicine use: Takes TUMS and Pepcid
8. Food and nutrition related
history
Anthropometric
measurements
Biochemical data,
medical test and
procedures
Nutrition focus
and physical
findings
-Appetite: poor
- Regurgitation of some
foods
-reports pain upon
swallowing
-Nick usual dietary intake is
not rich in phytochemicals
and antioxidants. His only
consumption of vegetable is
at dinner. Nicks diet is high
in carbohydrates.
-patient daily consumption
of alcohol is 2 beers.
Patient current diet have
change to soft-liquid as he
present pain upon
swallowing especially foods
with course or crunchy
texture.
He cut off the alcohol and
the coffee because they
produce him heartburn.
Patient decrease protein
consumption and cut off all
the greens in his diet.
-patient currently status is
NPO with TPN
postoperatively progressing
to tube feeding as tolerated.
HT: 1.90m
UBW: 100 kg
CBW: 86.3
Usual BMI: 27.7
(overweight)
Current BMI: 23.8
(normal)
A severe weight loss
of 13.6% in the past
3-4 months.
Procedures:
-X-ray
-endoscopy and
biopsy
-Transhiatal
esophageal
esophagectomy
-Jejunal tube placed
for later feeding
-Radiation planned
post-operatively.
Biochemical data:
-patient present
decrease levels of
albumin,
prealbumin,
transferrin and TP,
RBC, HMG, HCT.
-thin.
-pale
-eyes sunken
- sclera clear
-Dry mucus
membranes.
-dry and warm
skin
- Chest/lungs:
cleat to
auscultation and
percussion
- Abdomen:
epigastric
tenderness
- Difficulty
swallowing.
-heartburn.
-Temp 98.3
(normal)
-BP 132/90 (high
blood pressure)
-HR 88 bpm
(normal)
- RR 13 bpm
(normal)
PES statement:
Food- and nutrition-related knowledge deficit related to lack of education and counseling
for appropriate medical nutrition therapy as evidence by food history food choices and 24
hour recall. (NB-1.1)
Nutrition intervention:
Goal: patient will be able to increase his calorie intake by eating easy digest foods. He will select
high nutrient dense foods wish won’t cause any discomfort when swallow or heartburn.
This will be accomplish by assisting to nutrition education interventions and counseling.
Nutrition prescription: patient will learn to eat small frequent meals consisting in nutrient dense
foods, low in fat foods. His fluid consumption will be between meals.
9. Nutrition education: Nick’s knowledge will increase about what foods to select and how to
prepare them after an esophagectomy. He will increase foods containing phytochemicals
and antioxidants which are recommended to increase health. Discuss different source of
proteins, energy dense smoothies and foods Patient will tolerate. He will be advice to
discontinue any consumption of alcohol.
Nutrition counseling: coordinate with patient and wife as she is the one who purchased and
prepared the food appropriate food and beverages options. Counselor will stablish weight
gain and increase physical activity.
Nutrition monitor and evaluation:
- Hydration status
- Any body weight trends
-increase in physical activity
- And increase albumin, prealbumin, total protein and transferrin levels.
11. The patient will receive outpatient radiation therapy following D/C. List additional
nutritional complications that may occur.
- Acute effects: Esophagitis, Dysphagia and odynophagia, heartburn, fatigue and loss of appetite.
- Late effects: ulceration, esophageal fibrosis and stenosis when this happen the individuals are
generally only able to swallow liquids, and use of medical food supplements and nutrition
support enteral nutrition may be necessary.
