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
https://www.dsld.nlm.nih.gov/dsld/dailyvalue.jsp
 Nutrition Care Manual. (n.d.). Retrieved April 2, 2018, from http://www.nutritioncaremanual.org/
 Immunotherapy. (n.d.). Retrieved April 05, 2018, from https://www.cancer.gov/about-
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
http://www.oatext.com/The-role-of-myeloid-derived-suppressor-cells-in-the-relationship-between-chronic-
obstructive-pulmonary-disease-and-lung-cancer.php