Jaclyn Cimiluca June 3, 2014Professor Sukumar Critical Care

Esophageal Cancer Treated with Surgery and Radiation

Nutrition Assessment: 1) Anthropometrics:

BMI= Weight (kg)/ Height (m2) 198 lb./2.2= 90kg 190.5 cm/100m= (1.905)2= 3.63 90 kg/ 3.63= 24.8 BMI IBW= 106 lbs. + (6 X 15 in.)= 196 lbs.(% IBW)= (ABW X 100)/ IBW=

(198 lbs. X 100)/ 196 lbs.= 101% IBWUBW= 228 lb.(% UBW) = %UBW= (100 X ABW) / UBW (100 X 198 lb.)/ 228 UBW= 87% UBW-> (13% weight loss in several months)Estimation of daily needs=Mifflin St. Jeor: 10 X (90kg) + 6.25 X (190.5cm) – 5 X 58 + 5= 1,796 = 2,334 kcal/day to maintain weight (activity factor 1.3)For weight gain: 30kcal/ 90kg=2,700 kcalEstimation of protein needs= 1.5-2.5 g/kg 90kg X 1.5= 135g protein/day or 90kg X 2.5= 225 g protein/dayEstimation of fluid needs= 30-35 mL/ kg X 90kg= 2,700- 3,150 mL

2) See printouts

3) Nutrient/Drug Interactions:

a. Tums (Calcium Carbonate)- Take separately from large amounts high fiber, high oxalate, or high phytate foods. Take FE, Zn, Mg or F separately by 1-2 hr. (Pronsky et al., 2012)b. Alka-Seltzer- Can interfere with absorption of bisphosphonates, tetracycline antibiotics, and quinolone antibiotics. Doctor should also be aware if the individual is taking digoxin, cellulose sodium phosphate, and certain phosphate binders. (WebMd, 2014)c. Pepcid-Take drug at least 2 hr. before or after Fe supplement. Take Mg supplement of Al/Mg antacids separately by at least 2 hr. Limit caffeine/xanthine. Decreased Fe and B12 absorption. Mg or Al/Mg antacids decrease drug absorption. (Pronsky et al., 2012)

4) Pertinent Laboratory Interpretations:

a. Bilirubin, direct (mg/dL): 0.3 (9/11)- High Bilirubin indicates that the cancer may have spread to the liver.b. Protein, total (g/dL): 5.7 (9/5), 5.7 (9/11)- Low protein levels are indicators of malnutrition and muscle wasting. c. Albumin (g/dL): 3.1 (9/5), 3.0 (9/11)- Low albumin levels are indicators of malnutrition and muscle wasting. d. Pre-albumin (mg/dL): 15 (9/5), 12 (9/11)- Low pre-albumin levels are indicators of malnutrition and muscle wasting. e. RBC (X106/mm3): 4.2 (9/5), 4.3 (9/11)- Low RBC levels could be a result of nutritional deficiency, blood loss during surgery, or radiation treatment. f. Hemoglobin (Hgb, g/dL): 13.5 (9/5), 13.9 (9/11)- Low hemoglobin levels could be a result of nutritional deficiency, blood loss during surgery, or radiation treatment. g. Hematocrit (Hct, %): 38 (9/5), 38 (9/11)- Low hematocrit levels could be a result of nutritional deficiency, blood loss during surgery, or radiation treatment. h. Mean cell Jgb (pg): 32.4 (9/5), 32.3 (9/11)- High mean cell Jgb indicates the presence of macrocytic anemia which can be caused by B12 and folate deficiency, and from medication or alcohol use.i. Mean cell Hgb content (g/dL): 65.5 (9/11)- High mean cell Hgb content indicates the presence of macrocytic anemia which can be caused by B12 and folate deficiency, and from medication or alcohol use.

5) Medical/Social History: Mr. Seyer has dealt with heartburn for the past year. He takes TUMS, Alka-Seltzer, and Pepcid AC for this. He has also experiences dysphagia in the past 3-4 months, along with odynophagia in the past 5-6 months. He has a noted weight loss of 30 lbs. in the last several months as a result of pain and heartburn. He met with his doctor on 9/5 to address his heartburn and difficulty swallowing. He also complains of a recent decreased appetite, feeling full all the time, and that he sometimes regurgitates his food. Mr. Seyer is married with three sons, one who still lives at home. He works 5-6 days a week and often works greater than 12-hour days. Mr. Seyer and his wife are both smokers. He reports to smoke about 2 packs per day. He also consumes alcohol, 1-2 times per week. His mother died of liver cancer when she was 58.

SOAP Note: S: Patient complains that he is unable to eat due to symptoms of significant heartburn and pain for the past 4 to 5 months. He reports to have difficulty swallowing; especially anything with texture and that food seems to “hang up” in his throat in the upper portion of his neck. He also complains of recurrent cough at night. The patient attributes his reduced dietary intake to his decreased appetite, constant heartburn, and pain upon swallowing.

O: 58 yo. Caucasian. Ht, 6’3. Wt, 198 lbs. IBW, 196 lbs. %IBW, 101. UBW, 228 lbs. %UBW, 87. BMI, 24.8.

Dx: Stage IIB (T1, N1, M0) adenocarcinoma of the esophagusLabs: Protein, total (g/dL): 5.7 (9/5), 5.7 (9/11)

Albumin (g/dL): 3.1 (9/5), 3.0 (9/11) Prealbumin (mg/dL): 15 (9/5), 12 (9/11) Hemoglobin (Hgb, g/dL): 13.5 (9/5), 13.9 (9/11) Hematocrit (Hct, %): 38 (9/5), 38 (9/11) EER: 2,334 kcal/day to maintain weight (activity factor 1.3)

For weight gain: 30 kcal/ 90kg=2,700 kcal EPR: 135g to 225 g protein/day

EFR: 2,700-3150 mL/day

Meds: TUMS, Alka-Seltzer, and Pepcid

A:

1) Unintended weight loss (NC 3.2) due to complications with self feeding associated with diagnosis of esophageal cancer, dysphagia, heartburn and inadequate oral intake as evidenced by loss of 13% body weight in last several months, loss of muscle mass,signs of malnutrition, and 24 hr. dietary recall.

2) Increased nutritional needs (NI 5.1) due to high metabolic stress and catabolic wasting related to esophageal cancer as evidenced by unintentional weight loss, low protein, albumin, and pre-albumin lab values and sub optimal hematological lab values.

P: 1) Minimizing starvation effects, prevent specific substrate deficiencies, and supporting the acute inflammatory response by modifying composition and density of meals and snacks until enteral nutrition is administered.

2) Assess adequate amount of calories provided to meet the increased energy demands of the patient and administer high energy, high protein diet to meet increased demands of metabolic stress caused by esophageal cancer.

3) Monitor fluid and electrolyte balance to maintain adequate urine output and normal serum electrolyte levels.

4) Monitor laboratory levels of serum albumin, pre-albumin, retinol-binding protein, and transferrin levels and clinical measures (triceps skin fold measurement and lean body mass) to identify if patients is at risk of malnourishment.

ADIME Note:

Assessment

- 58 year old male with Stage IIB (T1, N1, M0) adenocarcinoma of the esophagus - Ht, 6’3. Wt, 198 lbs. IBW, 196 lbs. %IBW, 101. UBW, 228 lbs. %UBW, 87. BMI, 24.8.

Medical History: Patient has experienced dysphagia for the past 3-4 months and odynophagia for the past 5-6 months. Patient has had a decreased appetite, feels full all the time, regurgitates some of his food and experiences pain upon swallowing due to constant heartburn. After a chest X-ray, endoscopy with brushing and biopsy, and CT scan, Mr. Seyer was diagnosed with Stage IIB (T1, N1, M0) adenocarcinoma of the esophagus. Family History: Mother died of liver cancer at age 58 Medication: TUMS, Alka-Seltzer, and PepcidLabs: Protein, total (g/dL): 5.7 (9/5), 5.7 (9/11) Albumin (g/dL): 3.1 (9/5), 3.0 (9/11) Pre-albumin (mg/dL): 15 (9/5), 12 (9/11) Hemoglobin (Hgb, g/dL): 13.5 (9/5), 13.9 (9/11) Hematocrit (Hct, %): 38 (9/5), 38 (9/11)Estimated Energy Intake:

Usual Dietary Intake: 2,122 kcal/day24-Hour Recall (recent): 584 kcal/ day

Estimated Energy Needs: 2,334 kcal/day to maintain weight (activity factor 1.3)For weight gain: 30kcal/ 90kg=2,700 kcal

Estimated Protein Needs:135g to 225g protein/day Estimated Fluid Needs: 2,700-3150 mL/dayDiet related behaviors: Patient complains that he is unable to eat due to symptoms of significant heartburn and pain for the past 4 to 5 months. He reports to have difficulty swallowing; especially anything with texture and that food seems to “hang up” in his throat in the upper portion of his neck. He also complains of recurrent cough at night. The patient attributes his reduced dietary intake to his decreased appetite, constant heartburn, and pain upon swallowing. Diagnosis 1) Unintended weight loss (NC 3.2) due to complications with self feeding associated with diagnosis of esophageal cancer, dysphagia, heartburn and inadequate oral intake as evidenced by loss of 13% body weight in last several months, loss of muscle mass, signs of malnutrition, and 24 hr. dietary recall.

2) Increased nutritional needs (NI 5.1) due to high metabolic stress and catabolic wasting related to esophageal cancer as evidenced by unintentional weight loss, low protein, albumin, and pre-albumin lab values and sub optimal hematological lab values.

Intervention

1) Modify composition and density of meals and snacks until enteral nutrition is administered.

2) Administer high energy, high protein diet to meet increased demands of metabolic stress caused by esophageal cancer.

Monitoring and Evaluation 1) Minimizing starvation effects, prevent specific substrate deficiencies, and supporting the acute inflammatory response.

2) Monitor fluid and electrolyte balance to maintain adequate urine output and normal serum electrolyte levels.

3) Assess adequate amount of calories provided to meet the increased energy demands of the patient.

4) Monitor laboratory levels of serum albumin, pre-albumin, retinol-binding protein, and transferrin levels and clinical measures (triceps skin fold measurement and lean body mass) to identify if patients is at risk of malnourishment.

Case Study 33: Esophageal cancer treated with surgery and radiation

1. Mr. Seyer has been diagnosed with adenocarcinoma of the esophagus. What does the term adenocarcinoma mean?

Adenocarcinoma is neoplasia of epithelial tissue that exists in the mucus-secreting glands of the body. Malignant cancer forms in the glandular cells or columnar tissues of the esophagus in individuals with esophageal adenocarcinoma.

2. What are the two most common types of esophageal cancer? What are the risk factors for development of this malignancy? Does Mr. Seyer’s medical record indicate that he has any of these risk factors?

The two most common types of esophageal cancer are squamous cell carcinoma and adenocarcinoma. Risk factors include drinking alcohol, bile reflux, achalasia, drinking hot liquids, eating few fruits and vegetables, GERD, obesity, Barrett's esophagus, radiation treatment in chest or abdomen, and smoking. Mr. Seyer’s medical record indicates that he has history of heartburn, has difficulty swallowing, and that he smokes and drinks putting him at risk for esophageal cancer.

3. Mr. Seyer’s cancer was described as Stage IIB (T1, N1, M0). Explain this terminology used to describe staging for malignancies.

In the Tumor Node Metastases Staging System, the tumor is classified as a “stage” based on cell type, tissue origin, whether it is benign or malignant, degree of differentiation, anatomic site, and function. This classification system assists with treatment planning, provides prognosis, aids in treatment evaluation, and helps to identify individuals for clinical trials. In Mr. Seyer’s diagnosis, T1 describes the tumor’s size and/or level of invasion in to nearby structures, N1 describes the size, location and/or the number of lymph nodes involved, M0 means that no distant metastases were found. Once T, N, and M are determined an overall stage is given.

4. Cancer is generally treated with a combination of therapies. These can include surgical resection, radiation therapy, chemotherapy, and immunotherapy. The type ofmalignancy and staging of the disease will, in part, determine the types of therapies that are prescribed. Define and describe each of these therapies. Briefly describe the mechanism for each. In general, how do they act to treat a malignancy?

In surgical resection abnormal cancer tissue is removed. In radiation therapy high-energy particles or waves destroy cancer cells by altering cellular and nuclear material. This is the most common form of treatment. Chemotherapy involves the use of medicine and/or drugs that interrupt different stages of cell cycle replication. In immunotherapy, the immune system is used to treat cancer. Immunotherapy aggravates the immune system to attack cancer cells by using cancer antigens and targets.

5. Mr. Seyer had a transhiatal esophagectomy on 9/7. Describe this surgical procedure. How may this procedure affect his digestion and absorption?

The purpose of a trans hiatal esophagectomy is to restore comfortable swallowing with the replacement of the stomach for the esophagus. During a trans hiatal esophagectomy an incision is made in the abdominal and in the left neck. The stomach is cut into the shape of a tube using staples. The esophagus and cut part of the stomach are pulled through the neck incision. The stapled stomach is brought up and then sewn to the piece of the esophagus left in the neck. The stomach then functions as the esophagus did. In this procedure, the vagus nerve is removed and the pyloric muscle is cut. Therefore, fats and sugars will not be able to be digested in the same manner. “Dumping syndrome” also commonly occurs affecting digestion and absorption.

6. Many cancer patients experience changes in nutritional status. Briefly describe the potential effect of cancer on nutritional status.

Cachexia is one of the most common causes of death in cancer patients and is characterized by involuntary weight loss, tissue wasting, inability to perform daily activities and metabolic alterations. Individuals with cancer experience abnormalities in carbohydrate, protein, and lipid metabolism. The most profound carbohydrate abnormalities are insulin resistance, increased glucose synthesis, gluconeogenesis, increased Cori cycle activity, and decreased glucose tolerance and turnover. In cachexia, amino acids are not spared as they should be, and lean body mass is depleted. Abnormalities in lipid metabolism include decreased lipogenesis, increased lipid metabolism, and decreased activity of lipoprotein lipase.

7. Both surgery and radiation affect nutritional status. Describe potential nutritional and metabolic effects of these treatments.

Surgical treatment for esophageal cancer can delay recovery of oral intake, and a jejunal feeding tube is sometimes required after surgery. Surgical procedures such as a trans hiatal esophagectomy can cause abnormalities in lipid and carbohydrate metabolism because of removal of the vagus nerve, alterations in the pyloric muscle, and dumping syndrome. Radiation therapy can have deleterious effects on nutrition by interfering with ingestion, digestion or absorption of nutrients. When treating the head and neck area, common side effects of RT are fatigue, mucositis, dysgeusia, xerostomia secondary to salivary gland destruction, dysphagia, odynophagia, and severe esophagitis. There is also risk of dehydration, due to inadequate fluid intake. Irritation of esophageal tissue can make oral intake impossible. If tolerated, a feeding tube will be placed.

8. Calculate and evaluate Mr. Seyer’s % UBW and BMI.a. Mr. Seyer’s % UBW:

%UBW= (100 X ABW) / UBW (100 X 198 lb.)/ 228 UBW= 87% UBWb. Mr. Seyer’s BMI

BMI= Weight (kg)/ Height (m2) 198 lb. /2.2= 90 kg 190.5 cm/100 m= (1.905)2= 3.63 90 kg/ 3.63= 24.8 BMI

9. Summarize your findings regarding his weight status. Classify the severity of his weight loss. What factors may have contributed to his weight loss? Explain.

Although Mr. Seyer has a healthy BMI of 24.8, he used to be obese and has experienced rapid weight loss of 13% in the past several months. This puts him in a severe weight loss category. Some factors contributing to his weight loss may include symptoms affecting oral intake such as dysphagia and heartburn Mr. Seyer reports that he has difficulty swallowing and that food sometimes “hangs up” in his throat. His acid-reflux also has effects on his appetite.

10. What does research tell us about the relationship between significant weight loss and prognosis in cancer patients?

Malnutrition is a major concern in cancer patients and in severe cases can lead to cachexia. Weight loss can also occur before cancer symptoms are exhibited. Research done by Argiles, in 2005 says that in 45% of patients, a pre-diagnostic weight loss of greater than 10% is seen. Cachexia occurs in 30-85% of all cancer patients. High incidence of cachexia is seen in esophageal (80%), head and neck (70%), lung (60%), and colorectal (60%). Weight loss from cancer occurs as a result of nutrition needs not being met as a result of poor food intake, decreased absorption and/or assimilation, and increased nutrient loss due to tumor metabolism.

11. Estimate Mr. Seyer’s energy and protein requirements based on his current weight.Mr. Seyer’s Energy and Protein Requirements:

a. Mifflin St. Jeor:10 X (90 kg) + 6.25 X (190.5cm) – 5 X 58 +5 = 1796

= 2334 kcal/day to maintain weight (activity factor 1.3) For weight gain:

30 kcal/90kg= 2700 kcal b. Protein Needs:Because Mr. Seyer has experienced extreme weight loss and is at risk for wasting his protein needs would be 1.5-2.5 g/kg.

90kg X 1.5= 135g protein/dayor

90kg X 2.5= 225 g protein/day 12. Estimate Mr. Seyer’s fluid requirements based on his current weight.

Fluid Requirements:30-35 mL/kg X 90kg=

2,700- 3,150 mL

13. What factors noted in Mr. Seyer’s history and physical may indicate problems wtih eating prior to admission?

Mr. Seyer has been experiencing dysphagia for 3-4 months, heartburn for the past 4-5 months, and complains that when eating food sometimes “hangs up” in his throat. All of these factors are contributors to Mr. Seyer’s inadequate caloric intake and weight loss.

14. Mr. Seyer's is currently receiving enteral nutrition, specifically Isosource HN at 75 mL/hr.

a. Calculate the amount of energy and protein that will be provided at this rate. Energy: 75mL/hr / 250 mL x 300 kcal = 90 kcal/hrProtein: 75mL/hr / 250 mL x 13.4 G PRO = 4.02 g PRO/hr

b. Next. By assessing the information on the intake/output record, determine the actual amount of enteral nutrition he received on September 11.

Energy: 1735mL / 250 mL x 300 kcal = 2,082 kcalProtein: 1735 mL / 250 mL x 13.4 g PRO = 93 g PROFat: 1735 mL / 250 mL x 9.8 g Fat = 67.6 g FatCarbohydrate = 1735 mL /250 mL x 40 g CHO = 276 g CHO

c. Compare this to his estimated nutrient requirements.Mr. Seyer’s estimated nutrient requirements are 2,700 kcal/day and his intake via enteral nutrition is 2,082kcal/day. He is not receiving the adequate amount of nutrition.

d. Compare fluids required to fluids received. Is he meeting his fluid requirements? How did you determine this? Why would you evaluate his output when assessing his fluid intake?

Mr. Seyer’s his required fluids are 2,700- 3,150 mL and total fluids received are 3,972 mL (I.V. and P.O. flush). We determined the value of his fluid intake by taking into account that the enteral formula he was taking contained 82% water; this added 1422 mL to the 2,400mL from I.V. and 150 mL from flush. Mr. Seyer’s output should be evaluated when assessing his fluid intake in order to determine the level of fluid retention, consequent hydration, and homeostasis he is experiencing. Fluid and electrolyte balance is must be closely monitored to maintain adequate urine output.

15. What type of formula is Isosource HN? One of the residents taking care of Mr. Seyer's asks about a formula with a higher concentration of omega-3-fatty acids, antioxidants, arginine, and glutamine that could promote healing after surgery. What does the evidence indicate regarding nutritional needs for cancer patients and, in particular, nutrients to promote postoperative wound healing? What formula may meet this profile? List them and discuss why you chose them.

Isosource is a standard formula or polymeric formula with a high nitrogen content that is recommended for patient with general malnutrition and elevated protein requirements. Studies have shown that the use of formulas with a higher concentration of omega-3-fatty acids, antioxidants, arginine, and glutamine are helpful in the healing process for many reasons. Higher concentrations of omega-3-fatty acids have been shown to be a preferred energy source in patients with sepsis, even in the presence of adequate glucose stores. (118-120). Antioxidants, such as vitamins A and C, function as cofactors in many processes involved in wound repair and healing. 105 Arginine and glutamine are necessary amino acids in the growth and wound healing process which may have immunomodulatory functions that modify cancer cachexia. Pivot 1.5 Cal is a therapeutic; peptide based very high protein nutrition formula designed for metabolic stress of surgical, trauma, burn, and head and neck cancer. This product contains

arginine, glutamine, and omega-3-fatty acids to help modulate inflammation and support immune function. It also contains elevated antioxidant levels of vitamin C, vitamin E, and beta-carotene to help reduce free radical damage.

16. Are any clinical signs of malnutrition noted in the patient’s admission history and physical?

Yes, there are signs of malnutrition noted in the patient. According to the “Malnutrition Universal Screening Tool”(MUST), Mr. Seyer’s is at risk of malnutrition. He has had an unplanned loss of weight of more than 10% of UBW in the past 3-6 months and he is acutely ill. He also shows signs of anemia and hypoproteinemia.

17. Review the patient’s chemistries upon admission. Identify any that are abnormal and describe their clinical significance for the patient, including the likely reason for each abnormality and its nutritional implications.

Abnormal Labs Ref. Range 9/5 0832

Protein, total (g/dL) 6-8 5.7Albumin (g/dL) 3.5-5 3.1Prealbumin (mg/dL) 16-35 12Pt (sec) 12.4-14.4 12RBC (x 106 /mm3) 4.5-6.2 M 4.3Hemoglobin (Hgb, g/dL) 14-17 13.5 Hematocrit (Hct, %) 40-54 M 38 Mean Cell Hbg (pg) 26-32 32.4

The low protein, albumin, and prealbumin are related to the low intake of protein Mr. Seyer’s is experiencing due to his lack of nutrient intake. Low protein levels have been linked to muscle wasting accompanied by muscle wasting, as well as an immunocompromised system.

The low RBC, hemoglobin, hematocrit, and mean cell Hbg are related to the a lack of iron in Mr. Seyer’s diet, again due to his lack of nutrient intake. Although he is not anemic, considered with hemoglobin levels of 11g/dL or lower, the condition is of concern and should be addressed with increased nutrition and supplementation, if needed.

18. Mr. Seyer’s has been diagnosed with a life-threatening illness. What is the definition of terminal illness?

A terminal illness is an irreversible condition (it cannot be cured) that in the near future will result in death or a state of permanent unconsciousness from which you are unlikely to recover. In most states, a terminal illness is legally defined as one in which the patient will die “shortly” whether or not medical treatment is given. Some states require death to be expected within a certain number of hours or days. In those states, life-sustaining treatment could continue, even though the patient is terminally ill and mentally incompetent, until just hours or days before death would be expected.

http://www.cancer.org/treatment/findingandpayingfortreatment/understandingfinancialandlegalmatters/advancedirectives/advance-directives-types-of-advance-health-care-directives

19. The literature describes how a patient and his family may experience varying levels of emotional response to a terminal illness. These may include anger, denial, depression, and acceptance. How may this affect the patient’s nutritional intake? How would you handle these components in your nutritional care? What questions might you have for Mr. Seyer or his family?

Terminally ill patients lack hunger due to a number of reasons ranging from bloating, anorexia, constipation, Xerostomia, taste change, nausea, vomiting, and dysphagia. The lack of nutritional intake by a patient with cancer is problematic for health reasons but is also distressing to the family members. Deceased intake of solid foods especially, is common as death becomes imminent because patients lose the will to continue fighting. Decisions regarding the nutritional support should be made with some questions directed to Mr. Seyer’s and his family:1. Will quality of life be improved?2. Do the potential benefits outweigh the risks? 3. Is there an advance directive?4. What are the wishes and needs of the family?

20. Select two high-priority nutrition problems after Mr. Seyer’s surgery and complete the PES statement for each.

Unintended weight loss (NC 3.2) due to complications with self feeding associated with diagnosis of esophageal cancer, dysphagia, heartburn and inadequate oral intake as evidenced by loss of 13% body weight in last several months, loss of muscle mass,signs of malnutrition, and 24 hr dietary recall.

Increased nutritional needs (NI 5.1) due to high metabolic stress and catabolic wasting related to esophageal cancer as evidenced by unintentional weight loss, low protein, albumin, and prealbumin lab values and sub optimal hematological lab values.

21. For each PES statement you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on etiology).

Goals are to minimizing starvation effects, prevent specific substrate deficiencies, and support the acute inflammatory response. Both PES statements are related to the most common and deleterious nutritional concern encountered by cancer patients. Malnutrition must be addressed clinically because protein and calorie deficiencies affect all aspects of treatment and recovery. Patients experiencing malnutrition respond poorly to surgery, have impaired wound healing post surgery, and may suffer complications postoperatively.

Appropriate intervention: Modify composition and density of meals and snacks until enteral nutrition is administered. High energy, high protein diet to meet increased demands of metabolic stress caused by esophageal cancer.

22. Does this current nutrition support meet his estimated nutritional needs? If not, determine the recommended changes. Discuss any areas of deficiency and ideas for implementing a new plan.

The current nutrition support does not meet his estimated nutritional needs; based on our calculations Mr. Seyer’s should be receiving an additional 600 kcal. We estimate that with an increased rate of 100 mL/hr, the patient will receive 120 kcal/hr allowing him to receive an estimated 2,760 kcal/day.

23. How may these interventions (from #21) Change as he progresses postoperatively? Discuss how Mr. Seyer may transition from enteral feeding to an oral diet.

Studies have shown that a transition from enteral feeding to an oral diet is a complex procedure that should institute a set plan of implementation. According to Crary and Groher, there are valuable suggestions for transitioning a patient from tube to oral feeding. The first phase is termed the preparatory phase which focuses on the physiological readiness of the patient for oral nutrition and incorporates medical and nutrition stability with intermittent tube feedings and swallowing assessments. The second phase, described as weaning, is the gradual increase in oral feeding with a corresponding decrease in enteral feeding. Tube feedings can be discontinued once the patient can consume 75% or more of their nutrition requirements consistently by mouth for 3 days.

24. List the factors you should monitor for Mr. Seyer while he is receiving enteral nutrition therapy.

While receiving enteral nutrition therapy, Mr. Seyer’s should be monitored for any further weight loss within the context of time with the Scored PG-SGA criteria. Serum hepatic proteins (albumin, prealbumin and transferrin) should also be monitored because they have a long half-life and are not affected by short-term changes. Serum hepatic protein levels can assist in identifying if the patient is a risk for developing serious nutritional deficits. Patients with decreased levels are less likely to meet energy and nutrient requirements to volition and will require an aggressive nutrition therapy.

25. Mr. Seyer will receive radiation therapy as an outpatient. In question #7, you identified potential nutritional complications with radiation therapy. Choose one of these nutritional complications and describe the nutrition intervention that would be appropriate.

Xerostomia is a common complication of radiation therapy hindering the production of saliva and consequent ingestion of nutrients. Nutrition intervention for this condition include the use of saliva stimulant and saliva substitutes, as well as a soft food diet to ease in swallowing.

26. Identify major assessment indices you would use to monitor his nutritional status once he begins therapy.

Reasonable goals for nutritional support in the critically ill patient include minimizing starvation effects, preventing specific substrate deficiencies, and supporting the acute inflammatory response. These issues must be addressed until the hypermetabolic state has resolved and healing begins. Fluid and electrolyte balance should be attained, and an adequate

amount of calories should be provided to meet the increased energy demands of the patient. Fluids and electrolytes must be judiciously administered to maintain adequate urine output and normal serum electrolyte levels. To objectively assess nutritional balance, several laboratory and clinical measures are available to identify patients at risk of malnourishment. Laboratory assessment of serum albumin, prealbumin, retinol-binding protein, and transferrin levels; cutaneous energy testing of immune responsiveness and total lymphocyte count; and physical determinants like triceps skin fold measurement and lean body mass may be utilized and followed clinically.

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