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Voss Major Case Study
Voss Major Case Study
Voss Major Case Study
Cancer:
A Major Case Study
Kirsten Voss
ISU Dietetic Intern, Class of 2017
Outline and Objectives
Outline
Objectives
1. Basic patient info
Gainbasic understanding of head
2. Head and Neck Cancer
and neck cancers, including MNT
3. Refeeding Syndrome recommendations.
4. Timeline of Care
Understand the causes, risk
5. Review Coordination of Care factors, prevention steps, and
6. Initial Assessment treatment of refeeding
syndrome.
7. Nutrition Follow Ups
Assessnutrition care provided to
8. Discharge Plans
post-hemiglossectomy patient.
9. Reflection
Patient Information
Name: CM
79 YO white male
2daughters; 1 granddaughter
55 (1.651 m)
who assists with care
Admit weight: 136 lbs (61.689 kg)
Drug Use History
BMI 21.6, normal
Based on 130 lbs (58.968 kg) at initial
Former smoker of 2 packs/day x
assessment 2/1 40 years; quit in 2000
Admit 1/31/17 to 4 Ham Surgical Floor Chewed tobacco/snuff in 1950s
my
Patient Information
MST 2: unintentional weight
loss of unsure amount Medications
Weight History Simvastatin, Symbicort, Coreg,
10 lb (7.1%) weight loss in 1 Cleocin IV, Digoxin, Pepcid,
year Lisinopril, Duragesic patch,
3 lb (2.3%) weight loss in 6
Synthroid, Flomax, Peridex, low
dose aspirin
months
Warfarin at home; held for
surgery
Head and Neck Cancers
Esophageal, hypopharyngeal, Risk factors
Highest incidence in black males
laryngeal, lip, oral cavity, Tobacco linked to 85% of cases
parathyroid, salivary glands Heavy alcohol use
Tongue cancer = most common Obesity
type of mouth cancer Male
Older than 50 years
3-5% of all cancer cases in US Chronic inflammation from gastric acid
exposure
Metastases to cervical lymph Radiation to head and neck
nodes HPV
Prognostic indicator Sun exposure (lip cancer)
Industrial exposures
Asbestos exposure
Head and Neck Cancers
Medical treatment
Multi-modalities Symptoms with nutritional
Surgery impact
Often with lymph node dissection Anorexia
Radiation Dysphagia
Chemotherapy
Xerostomia
Many patients malnourished Mucositis
Either the patient has one or Or the patient has two or more
more of the following: of the following:
Body Body mass index <18.5
mass index (kg/m2) <16
Unintentional weight loss >10% in the
Unintentionalweight loss >15% in
past three to six months
the past three to six months
Little or no nutritional intake for >5
Little or no nutritional intake for >10 days
days
Historyof alcohol misuse or drugs,
Lowlevels of potassium, phosphate, including insulin, chemotherapy,
or magnesium before feeding antacids, or diuretics
Refeeding Syndrome Intervention &
Prevention
Start nutrition support slowly
15-20 kcal/kg first 3 days
Protein 1.2 g/kg, work up to 1.5 Electrolyte correction
g/kg IV replacements
150-200 g CHO Mg, Phos, K
May need fluid restriction 800- Correct before feeding
1000 mL Insulin for hyperglycemia
Work up to goal rate by day 7
Low infusion rates Thiamine boluses
Timeline Summary
Date
1/31/1 Pt admitted, laser hemiglossectomy completed by Dr. Lansford
7
2/1/17 Initial assessment; TF trickle feeds initiated via NGT; goal rate 32 mL/hr
2/2/17 PEG tube placed; work up to continuous goal rate of 32 mL/hr
2/3/17 MD consult to increase TF rate and transition to bolus feeds; goal rate of 32
mL/hr
2/4/17 Weekend: seen by Tracy Anderson, RD; Phos rider given
2/5/17 Weekend: seen by Tracy Anderson, RD; increased goal rate to 38 mL/hr
2/6/17 Increased goal rate to 45 mL/hr
2/7/17 MD increased goal rate to 55 mL/hr; switched to bolus feeds with increased
formula volume
2/8/17 Continued bolus feeds
2/9/17 Met with Pt and granddaughter about home plan; Pt D/C in afternoon
3/1/17 Follow up phone call to granddaughter and Option Health
Coordination of Care
RD Team: Tracy Anderson, Kim Kelley, Tracy
Trebian
RN Team: Britney, Abby, Misty, Sally
Case Manager: Susan
MD Team: Dr. Lansford, Dr. Geraughty,
Dr. Gootee, Dr. Reddivari
Option Health home infusion services:
Tammie
Family Support: granddaughter
Initial Assessment: 2/1/17
RD consult to start trickle tube feeding (TF) via nasogastric tube (NGT)
Diet order: NPO except sips with meds
IVF D5 0.45% NaCl w/ KCl 20 mEq at 100 mL/hr
Labs: BUN 22, GLU 103
Pt interview:
Usual body weight: 131 lbs
Hardly ate at all 1 month PTA due to tongue pain , <50% of usual intake
Felt like lost weight, unsure of amount or time period
No oral supplements at home
Residuals <15 mL
Follow Up 5: 2/6/17
Phos 2.8, WDL OptionHealth home infusion
Trending up after weekend Phos rider services
Residuals <15 mL Intervention:
increase TF rate to 45
8.4 lb (3.8 kg) wt increase mL/hr x 22 hrs
Fluid retention? 25 kcal/kg
Non-pitting edema RLE, LLE 1.07 gm pro/kg
Challenges?
Completed care during Weeks 4-5
MDs wanting to ramp up TF too quickly
Done differently?
Completed NFPA during initial assessment
Diagnosed malnutrition
Ordered complete labs sooner
Should have ordered Phos, Mg on 2/1, instead of 2/2
Correct hypophosphatemia before feeding
References
Academy of Nutrition and Dietetics. (2007). Oncology guideline. Evidence Analysis Library.
DeFronzo, R.A., Cooke, C.R., Andres, R., Faloona, G.R., & Davis, P.J. (1975). The effect of insulin on renal handling of sodium,
potassium, calcium, and phosphate in man. Journal of Clinical Investigation, 55 (4), 845-855. https://doi.org/10.1172/JCI107996.
Escott-Stump, S. (2012). Nutrition and diagnosis-related care (7th ed.). Baltimore, MD: Lippincott Williams & Wilkins.
Leser, M. & Sappah, L. (2016). Oncology: cancer sites; head and neck. Nutrition Care Manual.
Mahan, L.K., Escott-Stump, S., & Raymond, J.L. (2012). Krauses food and the nutrition process (13th ed.). St. Louis, MO: Elsevier
Saunders.
Marinella, M.A. (2009). Refeeding syndrome: an important aspect of supportive oncology. Journal of Supportive Oncology, 7 (1),
11-16.
Mehanna, H.M, Moledina, J., & Travis J. (2008). Refeeding syndrome: what it is, and how to prevent and treat it. British Medical
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Mekhail TM, Adelstein DJ, Rybicki LA, Larto MA, Saxton JP, Lavertu P. Enteral nutrition during the treatment of head and neck
carcinoma.Cancer.2001;91:1785-1790
National Institute for Health and Clinical Excellence.(2006). Nutrition support in adultsclinical guideline CG32.