University of Maryland Dietetic Internship

Mini Case
Study

Ashley Spence

Nutrition Assessment: Medical Diagnosis Endometrial Cancer with metastases to the

liver, lungs, and bone (currently undergoing palliative chemotherapy treatment). FTT,
dehydration, pressure ulcer, UTI, hyponatremia, leukocytosis.
Age: 78
Labs:
Gender: Female
11/09
11/10
11/11
Weight: 40.8kg (90#)
Glucos 84
59 (L)
109
Height: 162.6cm (53)
e
BMI: 15.5, underweight
Na
130 (L) 134 (L) 131 (L)
IBW: 54.25kg
K
4.7
4.1
4.1
%IBW: 75.21%
BUN
38 (H)
23
15
Cr
0.64
0.43
0.38
PMH
Ca
8.6
7.7 (L)
7.6 (L)
Endometrial cancer (mets lungs, liver,
* Hgb and Hct trending low for 11/12bone), HTN, hypercholesterolemia,
11/14
diverticular disease, lymphadenopathy,
*Alk Phos 134 (H) 11/9
arthritis.
Skin Status
Symptoms
Pressure ulcer, stage 3 at left buttocks
Weakness, abdominal pain, poor po > 3
days, weight loss
Medications:
Per chart:
Scheduled:
10/27-44 kg (97#)
Aspirin (non-steroidal, anti-inflammatory)
5/20-58.9 kg (129#)
Heparin (anticoagulant)
Morphine (narcotic, constipation)
18.1 kg wt change in 5.5 months (per
Vancomycin (antibiotic)
chart), -30% wt change-severe.
Pt reported UBW 168#, involuntary wt PRNTylenol (pain reliever, fever reducer)
loss occurred over last 8-9 months.
Mylanta (acid reliever)
Dilaudid (narcotic, constipation)
Diet History
Pt reported poor po and appetite PTA since Zofran (anti-nausea/vomiting)
July 2014 due to recent surgery. Pt also
reported having no taste for food and
Current Diet
difficulty chewing due to losing teeth. No
special diets or restrictions noted. No food 11/14-Dysphagia-Thin-Mechanically
Altered Diet
allergies noted. Visitor at bedside
11/14- Ensure daily (350 kcal, 13gm
(daughter) reported pt taking Megace at
protein) and Magic Cup daily (290 kcal, 9
home. Per chart, has not helped with
appetite. Pt reported taking a stool softener gm protein).
11/11-Regular Diet
(senokot and mineral oil) due to
complications with pain meds. Last
Initial Consult:11/11
chemotherapy was 10/2014; upcoming:
11/11(regular diet): pt c/o breakfast
11/2014. Last radiation was 10/2014food being too hard to eat. Amenable to
complications occurred and was
softer diet. Attempted to obtain food
discontinued. Pt reported taking boost 2x
preferences.
per day, MVI, and Vitamin D/Ca

combination.

Intake- Pt reported eating a few bites of

boiled egg and applesauce from
breakfast tray.

Nutrition Diagnosis utilize PES Statements

NI 5.2-Malnutrition related to loss of appetite and metastatic cancer as evidenced by
poor po intake since July 2014 and -30% weight change in less than 6 months.
NI 2.2-Inadequate oral intake related to loosing/missing several teeth as evidenced by
difficulty chewing and pt reported poor po intake > 3 days.
NI 5.1-Increased nutrient needs related to wound healing and cancer as evidenced by
documented stage 3 pressure ulcer and stage 4 metastatic cancer.
Nutrition Intervention Nutrition prescription, Interventions with goals
Nutrition Prescription
Intervention with goals
Dysphagia-Thin- Mechanically Altered Goal: PO Intake >25% of meals
ND 1.2- Recommend Mechanically
Kcal/mg formula used
altered diet (having difficulty chewing,
1224 Kcal/day-1632 Kcal/day
would not further restrict given
30 Kcal/kg min -40 Kcal/kg max
advanced age and predicted suboptimal
(metastatic CA, wound healing, wt
intake. Pt likes soft foods and would
gain)
like to try soft diet. Pt likes orange
Protein- 61-81 g/day- 1.5g/kg (min)juice, mashed potatoes, canned
2g/kg (max) (repletion, wound healing,
peaches, and ice cream. Will add snack.
metastatic CA)
ND 3.1.1- Recommend strawberry
ensure daily (350 kcal, 13g protein.
Recommend orange magic cup (290
kcal, 9 g protein).
ND 6.1- Consider re-adding Megace if
no contraindications, on Megace at
home but not receiving per chart.
Consider adding MVI/minerals if no
contraindications.
E 1.7- Discussed ways to add extra
calories to meals.
RC 1.4- Request nursing to weigh pt
weekly and document po intake.
Nutrition Monitoring and Evaluation
Indicator
Criteria
1. AD-1.1.2: Weight
1. Weight at least 44Kg. Unintentional wt
2. FH-1.1.1.1: PO intake/tolerance
loss is minimized.
3. BD-1.2, 1.5: Nutrition-related labs
2. Pt consumes at least 25% of meals.
4. PD-1.1.5: GI function
3. Normal levels of electrolytes from
5. PD1.1.7 Skin
blood drawings
4. No reports of N/C.
5. Stage 3 ulcers remains stable in size

and depth or improves.

Source

Kcal requirements

Facility standards

1224 -1632 kcal/day;

30-35+ kcal/kgwounds, cancer,
malnutrition

EAL

Harris Benedict for

Oncology (955.4 + SF)/
at least 30 kcal/kg
Harris Benedict for
Oncology (955.4)

Online nutrition care

manual

Protein
requirements
61-81 g/day-;
1.5g/kg -2g/kg
(repletion, wound
healing, CA)

Fluid requirements

N/A

N/A

1.5g/kg-2g/kg for
pressure ulcers
(61-81g)

25 ml/kg body weight

for >65 years
(1020ml)

25 ml/kg body weight

for >65 years
(1020 ml)

At F/U: 11/14
Per flow sheet, pt has average intake of 32% (6 meals). Consuming 15-50% of meals.
Pt reported appetite was still poor but was a little better. Daughter suggested po intake
approximately <25%.
Pt still c/o difficulty chewing even with softer foods due to missing teeth. Pt refused
downgrade to puree diet. No trouble swallowing was reported.
Pt reported eating nightly snack sometimes (RD ordered; ice cream).
Pt reported consuming supplements sometimes. Usually drinks 100% of ensure.
Pt now with C diff. Per chart poor prognosis. Family considering hospice.
References:
1. Academy of Nutrition and Dietetics Evidence Analysis Library. 2007 Oncology EvidenceBased Nutrition Practice Guidelines. Published 2007.
2. Academy of Nutrition and Dietetics. International Dietetics and Nutrition Terminology
(IDNT) Reference Manual. Chicago, IL: American Dietetic Association; 2013;
3. Academy of Nutrition and Dietetics. Nutrition Care
Manual. http://www.nutritioncaremanual.org. Accessed November 14-18, 2014.
a. http://www.nutritioncaremanual.org/topic.cfm?
ncm_category_id=1&lv1=22938&lv2=255467&ncm_toc_id=255467&ncm_heading
=Nutrition%20Care

b. http://www.nutritioncaremanual.org/topic.cfm?
ncm_category_id=1&lv1=5546&lv2=16668&ncm_toc_id=16668&ncm_heading=Nu
trition%20Care
c. http://www.nutritioncaremanual.org/topic.cfm?
ncm_category_id=11&lv1=255519&lv2=255701&ncm_toc_id=255701&ncm_headin
g=&
d. http://www.nutritioncaremanual.org/topic.cfm?
ncm_category_id=11&lv1=255287&lv2=255304&ncm_toc_id=255307&ncm_headin
g=&
4. The Clinical Guide to Oncology Nutrition, 2000.