Esophageal Cancer Treated with Surgery and Radiation Case Study (Evaluation and ADIME Note)

Esophageal Cancer Treated with Surgery and Radiation Case Study (Evaluation and ADIME Note)

Nutritional care plan: N.S. is a 58 yr old male. His serum albumin is below normal with a value of 3.1L (9/5) and 3.0L (9/11). His low albumin level may be due to stress, malnutrition, inadequate protein intake, and the disease itself. His total lymphocyte count is 28 (9/5) and 32 (9/11). Ht: 6 3 (190cm), UBW:230#(105kg), Current Wt: 198#(90kg), BMI 29(UBW)/24.9(current wt), %IBW: 98.9 % (196/198 x100), %UBW: 86% (198/230 x 100). N.S. has lost 14 % body weight(32 lbs / 230 lbs). This may be due to the fact that he has difficulty swallowing. N.S. s current body weight is in the normal range. His BMI is 24.9. Nutritional Diagnosis: 1. Inadequate oral intake R/T pain upon swallowing and heartburn AEB 24 hour recall. 2. Involuntary weight loss R/T poor appetite and swallowing difficulty AEB 30 lb weight loss in several months. Diet history: N.S.'s usual diet used to consist of eggs, bacon, and toast for breakfast. But because of his symptoms, most recently he only consumed coffee and cereal. For lunch, he used to eat cold sandwiches with cold cuts or leftovers from previous dinner. He also ate fruits, cookies, and tea. His dinners used to consist of different kinds of meats, pasta, rice, 2-3 vegetables, and 1-2 beers. For snack he would have ice cream, popcorn, or homemade dessert. His eating habits and dietary intake has dramatically changed in the past few months. These changes are due to his constant heartburn, painful and difficult

swallowing and loss of appetite. He complained of feeling full all the time, regurgitation of some foods, and recurrent coughs at night. Due to the dramatic changes in dietary intake N.S. has lost about 30 pounds in the past few months. He does not have any known food allergies, intolerances, or aversions. Previously, he did not follow any special therapeutic diet and was not under any treatment nor he taken any vitamins and minerals. Evaluation of laboratory findings: N.S. s albumin level of 3.0g/dl, total protein of 5.7g/dl, and prealbumin of 12 mg/dl were lower than normal value. These lab values indicated inadequate protein intake and protein loss of the patient. Transferrin value changed from 285 mg/dl to 175 mg/dl. The final value on September 11th was lower than normal range, which might indicate anemia. The causes could be esophagus internal bleeding and blood loss due to surgery. The lipid panel of the patient was at the high end of normal range. It is better to lower the lipid value through proper diet after recovery. Review of medications and food/nutrient interactions: N.S. is currently taking medications of TUMS, ALKA-Seltzer, and Pepcid. TUMS is a calcium carbonate supplement used when dietary calcium intake is not adequate, or used to relieve heartburn. It can cause side effects such as vomiting, dry mouth, and loss of appetite (3). ALKA-Seltzer and Pepcid are also medications for heartburn relief. Side effects caused by Pepcid are not common, but include constipation, diarrhea, fatigue, headache, insomnia, muscle pain, nausea and vomiting (4). Side effects associated with ALKA-Seltzer include nausea, vomiting, diarrhoea abdominal pain,

stomach or duodenal ulcer, and bleeding from the stomach or intestine (5). N.S. should cease all medications which may have been contributing his poor appetite and dry mouth. Evaluation of physical or clinical findings: The patient dropped 32lb in the past several months. It was a 14% weight change (32lb/230lb=14%) that indicated high nutritional risk. Also the patient complained heartburn and difficulty of swallowing in the past 4 to 5 months, which caused him not to be able to eat. Other physical findings included dry nose, throat and skin, muscle wasting at joints, and epigastric tenderness on palpation. Lab values related to protein status, including albumin, total protein, prealbumin, were much lower than the normal range. RBC, HGB and HCT were also lower than normal value. This might indicate poor diet and insufficient nutrients such as iron and vitamin B12. Blood lipid value were at the high end of normal range. But this is not the primary concern in the current situation. The patient s tolerance to current diet order is 96%. He received 1735 ml of tube feeding formula out of 1800 ml of total prescribed formula on September 11th. Energy Requirements: The factor range used for cancer patients is 30-35 kcal/kg. The patient lost weight in the last few months, however, since he was overweight, his current weight of 90 kg is used in order to maintain it. Therefore, the estimated energy requirement is 2700 kcal. [30x90(current Wt)= 2700 kcal] Protein Requirements:

High protein factor is used due to the patient s increased protein needs such as muscle wasting, weight loss, post surgery and pre radiation therapy. Therefore, the estimated protein requirement is 135 g. [1.5x90(current Wt)= 135 g] Diet Order: N.S. should receive 2700 kcal, which will be divided to 55% carbohydrate (350g/540 kcal), 20% protein (135g/540 kcal) and 25% fat (80g/675 kcal). For fluid need, the range of 30-35 ml/kg is used for cancer patients (6), therefore, he should receive 3150 ml of fluid [90(current wt) x 35]. In addition, he should also receive supplements of vitamin, mineral, fatty acid and amino acid. Most cancer patient often have deficiency of vitamins and minerals such as vitamin C, folate, retinol, magnesium, zinc, copper and iron. Multivitamin and mineral supplements that contain <150% of the DRI may help micronutrient deficiency of cancer patients who receive chemotherapy and/or radiation therapy (6). Therefore, N.S. should receive 117 mg of vitamin C, 520 mcg of folate, 1170 mcg of vitamin A, 546 mg of magnesium, 14.3 mg of zinc, 1170 mcrg of copper, and 10.4 mg of iron, which are 130% of the DRI considering he has malnutrition and is planning to receive radiation therapy near future. In addition to those vitamins and minerals, vitamin B12 also should be supplemented due to low serum HGB, HCT, MCH and MCHC level. Omega-3 fatty acid, glutamine and arginine should be supplemented with formula to promote wound healing, however, the exact amount of duration for using those supplementation has not determined yet (6). In order to achieve the recommended diet specifications, Impact Advanced Recovery formula may be suggested. It contains 1.4kcal/ml, 45g/237ml of

carbohydrate, 18g/237ml of protein and 9.2g/237ml of fat (7). Based on the amount of tube feeding (75ml/h) for 24 hours, the energy intake of the patient would be 2520 kcal, 342g of carbohydrate (53%),137g of protein (22%), and 70g of fat (25%). The formula is especially designed for surgical patient, fortified with arginine, omega-3 fatty acid, and nucleotides to reduce the risk of infection after surgery. According to the record, the total fluid input is 4285 ml. N.S. received 1450 ml of IV, tube feeding formula and flush at night, 1385 ml during day, and 1450 ml in the evening on September 11th. (1450 ml+1385 ml+1450 ml = 4285 ml) There is no information about output, residual volumes, nausea, vomiting, stool frequency and consistency. Diet Therapy: The primary goal of dietary treatment is to increase protein intake to preserve lean body mass and stop weight loss. Also, micronutrient supplement should be given in order to treat nutritional deficiency, help faster recovery from surgery and blood loss and decrease the risk of infection. The current diet order is not appropriate due to inadequate protein and excess fluid given to the patient, even though total energy of 2700 kcal is appropriate. N.S. is prescribed 122 g of protein and actually receives 117 g. However, he should intake 135 g of protein considering his muscle wasting, low albumin level, post-surgery, and preradiation therapy condition. Also, he receives 4285 ml of total fluid per day which is an excessive amount for his condition, while the recommended amount is 3150 ml. Since the amount of the formula and flush cannot be changed, IV volume should be decreased to 1200 ml (50 ml/h) from 2400 ml (100 ml/h). In addition, multivitamin and

mineral supplement is recommended including vitamin C, vitamin B12, folate, retinol, magnesium, zinc, copper and iron in order to treat their deficiencies and reserve blood loss. Omega-3 fatty acid, glutamine and arginine should also supplemented to promote surgery recovery and reduce the risk of infection. Nutritional Goals: Short-term goal is to increase lean body mass to promote recovery from the surgery and prepare for radiation therapy. It can be achieved by increasing protein intake and improve the lab values related to protein status such as albumin and total protein to the normal range in one month. Another goal is to correct the lab values related to blood loss such as transferrin, RBC, and HCT by multivitamin and mineral supplementation. Long-term goal is to maintain current weight of 90 kg during and after radiation therapy by accommodating the diet order according to the nutritional need change caused by the therapy. Eventually, the patient will switch to oral diet from tube feeding when he is capable. ADIME Note: Assessment: 58y/o Male Ht: 6 3 (190cm) UBW:230#(105kg) Current Wt: 198#(90kg) BMI 29(UBW)/24.9(current wt) Dx: Stage IIB (T1, N1, M0) adenocarcinoma of the esophagus Admitted with heartburn, dysphagia, odynophagia and 30 lb weight loss

Lab: Alb 3.1&3.0 g/dl, Total Protein 5.7&5.7 g/dl, Pre Alb 15 &12 mg/dl, Transferrin 175 mg/dl, RBC 4.2&4.3x10⁶/mm³, HGB 13.5&13.9 g/dl, HCT 38 & 38 %, MCH 3.24 & 32.3 pg, MCHC 36.5 g/dl, and ESR 17 mm/hr EER: 30x90(current Wt)= 2700 kcal EPR: 1.5x90(current Wt)= 135 g Fluid need: 35x90(current Wt)=3150 ml PMH: Leg fracture at age 14 and stitches due to lacerations from car accident Medications: TUMS, Alka-Seltzer, and Pepcid Diagnosis: 1. Inadequate oral intake R/T pain upon swallowing and heartburn AEB 24 hour recall. 2. Involuntary weight loss R/T poor appetite and swallowing difficulty AEB 30 lb weight loss in several months. Intervention: 1. Recommend 2700 kcal of energy, 350g of carbohydrate (55%, 540 kcal), 135g of Protein (20%, 540 kcal), 80 g of fat (25%, 675 kcal), and 3150 ml of fluid. Also recommend Impact Advanced Recovery 1.4kcal at 75 ml/hr x 24hrs. 2. Recommend to increase protein intake to 135g/d and reduce IV volume to 50 ml/hr. 3. Provide supplements: 117 mg of vitamin C, 520 mcg of folate, 1170 mcg of vitamin A, 546 mg of magnesium, 14.3 mg of zinc, 1170 mcrg of copper, 10.4 mg of iron (130% of the DRI), vitamin B12, omega-3 fatty acid, glutamine, and arginine. 4. Explain about OTC medications that the patient takes and recommend to stop taking them.

5. Involve the wife in consultation: provide a tip sheet about radiation therapy and how to manage its side effects. Monitoring/Evaluation: 1. Patient will increase protein intake to 135g and reduce fluid intake into 3150 ml. 2. Lab values related to protein status and blood loss will increase to the normal range in 1 month. 3. Patient will increase lean body mass in 2 months and maintain current weight of 90kg. 4.Patient will receive more than 90% of formula 5. Patient will show understanding of the side effects of OTC medication and stop taking them. 6. Patient will be monitored for tube feeding complication, bowel function, hydration/fluid status during enteral feeding. 7. Patient will follow up in one week Bibliography is at the bottom of the paper.