Initial Nutrition Assessment

A) Patient presents to outpatient cancer center for scheduled chemotherapy and

radiation appointments. PMH includes esophageal reflux, esophageal cancer.
WEIGHT: 208#
DIET HX: mechanical soft diet and thin liquids
PO INTAKE: poor; tries to drink plenty of water and eats soups, cabbage, drinks 3
Ensures per day
GI: abdomen soft, NT, ND, +BS, + J-tube
LABS: Na 142 WNL, K 4.5 WNL, Cl 103 WNL, CO2 26 WNL, BUN 9 WNL, Creat 0.74
WNL, BG 85 WNL, Ca 9.5 WNL, Alb 4.4 WNL, WBC 3.5 WNL, RBC 4.06 L, Hbg 12.3
L, Hct 36.6 L, Plt 189 WNL
MEDS: Oxycodone, Zofran, Carafate, Compazine, Roxicodone, Esomeprazole
SKIN: no documented wounds
Patient has significant weight loss of 69# over 10 months from 277# in January
2014 to 208# presently. Patient complains of decreased appetite, dysphagia, and
nausea and bloating with tube feeds. Discussed ways to increase hydration,
encouraged use of J-tube, and discussed protein rich foods that he can tolerate.
D) Inadequate energy intake (NI-1.4) related to esophageal cancer and treatment
as evidenced by unintentional weight loss of >5% in one month or >10% in six
months.
I) Isosource 1.5 at 110 milliliters per hour for 16 hours. This provides 2,625
calories, 118 grams of protein, and 1,358 milliliters of free water.
M/E) GOAL: Weight maintenance and tube feed regimen to provide 80-100% of
estimated nutrient needs. Will monitor weight, PO intake, GI symptoms, labs, and
meds. Follow-up in 3-5 days.