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Case Number: 3

Case Title: Malnutrition Associated with Chronic Disease



Semester: Spring 2016 Class: Medical Nutrition Therapy (NUTR 438B) Section: 1 Group: 5







Brief Description of the Case
Patient is a retired 68-year-old male admitted to acute care for possible dehydration, weight loss,
generalized weakness, and malnutrition. Patient complains of weakness, lack of energy, and states that he
gets full easily and never feels hungry. He was diagnosed with squamous cell carcinoma of the tongue
five years ago and had a partial glossectomy. Patient was treated with radiation therapy but has not
received treatment in the last 3 years. Medical history consists of essential hypertension, hyperlipidemia,
peripheral vascular disease, and weight loss of 60 lbs. in the last 2 years. Patient has chronic
inflammation; therefore, his condition is considered chronic disease-related malnutrition. Nutrition
intervention is important to rescue the body from distress by providing adequate amounts of vitamins and
minerals as well as overall adequate energy intake.

Updated 1/2015, Long Wang


Summary of the Disease Condition

Definition
Malnutrition is any nutritional imbalance, as observed in undernutrition or overnutrition. However,
malnutrition typically refers to undernutrition. Unintentional weight loss is the most common feature of
disease related malnutrition. The proposed overarching definition for malnutrition is a decline in lean
body mass with the potential to affect molecular, physiological, and gross motor functions (White,
Guenter, Jensen, Malone, & Schofield, 2012).

Epidemiology
According to the World Health Organization, malnutrition is prevalent in 20-60% of the population
(Imoberdorf & Ballmer, 2014). In a study conducted on cancer patients alone, the prevalence of
malnutrition was 30.9%. Besides examining the fact that oncology patients are at heightened risk for
malnutrition, the study also stated that those with head and neck cancers (which includes oral), are
especially at risk for malnutrition (Pressoir et al.).

Etiology
Malnutrition is a result of an imbalance of nutrients and energy provided to the body relative to its needs
(Alberda, Graf, & McCargar, 2006). Malnutrition risk increases with age or with illness. Adult
undernutrition occurs along a continuum of inadequate intake and/or increased requirements, impaired
absorption, altered transport, and altered nutrient utilization (White et al., 2012). Simply put,
malnutrition is due to an inadequate intake or assimilation of nutrients within the body. In order for
malnutrition to be diagnosed, an interpretation of past food and nutrient history, recent intake records, and
a comparison of estimated versus actual needs must be assessed. It is also often accompanied by weight
loss, noted changes in performed physical exams, loss of subcutaneous fat, a loss of muscle mass, the
presence of edema, and reduced grip strength (Nelms, Sucher, & Lacey, 2015). Oncology patients are at
high risk for malnutrition given their changes in taste and loss of appetite.

Pathophysiology
The most severe nutrition problem for malnutrition is inadequate oral intake. Patient is at risk of
malnutrition if dietary intake is impaired. Inadequate intake may be caused by common pre-existing
conditions such as organ diseases, chronic infections, cancer, and digestive disorders (Hssain, Souweine,
& Cano, 2010). Depletion of body cell mass results from reduced intake or assimilation of energy and/or
protein. Inflammation also promotes catabolism of skeletal muscle that is least in part cytokine mediated
(Jensen, et al., 2010).

Specific Examinations including Lab Indicators and Medical Diagnosis:
According to American Society for Parenteral and Enteral Nutrition (ASPEN) and the Academy of
Nutrition and Dietetics (AND), there are characteristics that may be examined to diagnose and detect
malnutrition (White et al., 2012). Such characteristics include: insufficient energy intake, weight loss, loss
of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation that may sometimes
mask weight loss, and diminished functional status as measured by hand grip strength. Only two or more
out of six of these characteristics need to be present in order for diagnosis (White et al., 2012). C-Reactive
Protein (CRP) is an inflammation contributor to malnutrition syndromes. Hemoglobin (HgB) are known
to transfer oxygen to cells, therefore the value is low when related to protein-energy malnutrition.
Transferrin, prealbumin, albumin, and BUN levels also decrease in malnutrition (Hssain et al., 2010).


Updated 1/2015, Long Wang

Medical Treatment
Currently, the typical form of treatment of malnutrition is through the use of commercial nutritional
supplements. Oral nutritional support has been shown to reduce the risk of morbidity and mortality in
older, hospitalized adults. Other forms of treatment include selective mid-meal trolley interventions. This
allows patients to choose snacks they desire from a passing trolley, in the hopes of increasing their overall
energy intake as they are familiar with the options available. This method is also used in the treatment of
malnourished pediatric patients. Another form of treatment is a dose feeding or MedPass program that
requires that a nutrient-dense formula of 2 mL/kcal be prescribed, delivered to the patient in small
dosages several times a day, and is indicated on the patients medical charts (Campbell, Webb, Vivanti,
Varghese, & Ferguson, 2013).

References Cited in This Summary
Alberda, C., Graf, A., McCargar, L. (2006). Malnutrition: etiology, consequences, and assessment of a
patient at risk. Best Pract Res Clin Gastroenterol, 20(3), 419-39.

Campbell, K. L., Webb, L., Vivanti, A., Varghese, P., & Ferguson, M. (2013). Comparison of three
interventions in the treatment of malnutrition in hospitalised older adults: A clinical trial.
Nutrition & Dietetics, 70(4), 325-331. doi:10.1111/1747-0080.12008

Hssain, A., Souweine, B., Cano, N. (2010). Pathophysiology of Resuscitation Malnutrition. Reanimation,
19, 423-430. doi:10.1016/ j.reaurg.2010.06.009

Jensen L. G., Mirtallo, J., Compher, C., Dhaliwal, R., Forbes, F., Hardy, G., & Waitzberg, D. (2010).
Adult Starvation and Disease-Related Malnutrition A Proposal for Etiology-Based Diagnosis in
the Clinical Practice Setting From the International Consensus Guideline Committee. Journal of
Parenteral and Enteral Nutrition. doi:10.1016/j.clnu.2009.11.010

Imoberdorf, R., Ballmer, P., (2014). Epidemiology of Malnutrition. Therapeutische Umsche, 71, 123-126.
doi:1024/0040-5930/a000492

Nelms, M., Sucher, K., Lacey, K., & Roth, S. L. (2016). Nutrition therapy and pathophysiology (3rd ed.).
Boston, MA: Cengage Learning

Pressoir, M., Desn, S., Berchery, D., Rossignol, G., Poiree, B., Meslier, M., & ... Bachmann, P. (2010).
Prevalence, risk factors and clinical implications of malnutrition in French Comprehensive
Cancer Centres. British Journal Of Cancer, 102(6), 966-971.

White, J., Guenter, P., Jensen, G., Malone A., & Schofield, M. (2012). Consensus Statement of the
Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition:
Characteristics Recommended for the Identification and Documentation Of Adult Malnutrition
(Undernutrition). Journal of the Academy of Nutrition and Dietetics, 112(5), 730-738.
doi:10.1016/j.jand.2012.03.012




Updated 1/2015, Long Wang

To Apply the Nutrition Care Process



Part One: Nutrition Assessment

Food/Nutrition
Related History

Biochemical
data, medical
tests, and
procedures
Lab data (e.g.,
electrolytes,
glucose) and tests
(e.g. gastric
emptying time,
resting metabolic
rate)

Food and nutrient


intake,
medication/herbal
supplement
intake,
knowledge,
beliefs, food and
supplies
availability,
physical activity,
nutrition quality
of life

1. Food and Nutrition History
Chief Complaint:
Usual Food and Nutrient Intake:
(for the past several months)

Nutrition Knowledge:
Physical Activity:
Food Availability:
Food Preferences:
Diet Hx:
Tobacco Use:
Alcohol Use:
Medications:

Comparative Standards
Energy:
UBW:
CBW:
25-30 kcal/kg:

Protein:
1.2 g/kg:

Updated 1/2015, Long Wang

Anthropometric
Measurements

Nutritionrelated Physical
Findings

Client History

Height, weight,
body mass
index(BMI),
growth pattern
indices/percentile
tanks, and weight
history

Physical
appearance,
muscle and fat
wasting, swallow
function, appetite,
and affect

Personal history,
medical/health/fam
ily history,
treatments and
complementary/alt
ernative medicine
use, and social
history

General weakness/energy deficiency


AM: egg, coffee, few bites of toast
Snack: can Ensure Plus
Lunch: soup or sandwich, milk
Dinner: few bites of soft meat, potatoes or rice. Tries to drink
the other can of Ensure Plus
N/A
N/A
N/A
N/A
Lost over 60 lbs in past 1-2 yrs. Lost weight when diagnosed w/
cancer 5 years ago. UBW: 220lb until after radiation therapy.
1 ppd 60+ years
1-3 can of beer/day
Lipitor 80mg daily
Capoten 25mg 2x/day

220 lb = 100 kg
156 lb = 71 kg
71 kg x 25 kcal = 1775 kcal
71 kg x 30 kcal = 2130 kcal
1.2 g x 71 kg = 85 g PRO

CHO, fiber (type, amount, distribution, if applicable):


45-65% CHO (AMDR):
1775 kcal x .45 = 799 kcal/4 kcal/g = 200 g CHO
1775 kcal x .65 = 1153 kcal/4 kcal/g = 288 g CHO
Fiber (14 g/1000 kcal for 65+): 25-28 g/day

Fat (type and amount, if applicable):
20-35% FAT (AMDR):
1775 kcal x .20 = 355 kcal/9 kcal/g = 39 g FAT
1775 kcal x .35 = 621 kcal/9 kcal/g = 69 g FAT

Vitamins and minerals, if applicable:
Vitamin C: >75 mg/day
Vitamin E: 15 mg/day
Vitamin K: 90-120 mcg/day
Folate: ~320 mg/day

Fluids:
30mL/kg: 2130 mL/day

Please summarize the key dietary intake information (if available) in the table below
This pt/ client
Expected, normal, or reference value
789 Kcal
1775-2130 Kcal
68 g pro
85 g pro
103 g CHO
200-288 g CHO
3 g fiber
25-28 g fiber
37.89 g fat
39-69 g fat
840 mL fluid
2130 mL fluid
Vitamin C 39 mg
Vitamin C >75 mg
Vitamin E 5 mg
Vitamin E 15 mg
Folate 220 mg
Folate ~320 mg
Vitamin K 29 mcg
Vitamin K 90-120 mcg
Interpretation and/or Comments: Dietary recall information shows inadequate energy, protein,
carbohydrate, fiber, fat, and fluid intake. Not only is patient not meeting macronutrients, he is not meeting
micronutrients such as Vitamin C, E, K, and folate.

2. Anthropometric Measurements
This pt/client
Expected or normal value
Gender: Male

Height: 63

Weight: 156 lbs
IBW: 196 lbs/UBW: 220 lb
BMI: 19.5 lb/in2
BMI: 25-30 lb/in2 for 65 y/o and older
Interpretation and/or Comments: Standing at 63 and weighing 156 lbs, male patient has a BMI of
19.5 lb/in2, classifying the patient as normal. Patients ideal body weight (IBW) is 196 lbs. Patient stated
that he lost over 60 lbs in the past 1-2 years.

3. Biochemical, Laboratory, and Diagnostic Tests
This pt/client
Expected or normal value
Chemistry
Chemistry
Sodium: 150 mEq/L
Sodium: 136-145 mEq/L
Potassium: 3.4 mEq/L
Potassium: 3.5-5.5 mEq/L
Updated 1/2015, Long Wang

Chloride: 118 mEq/L


Chloride: 95-105 mEq/L
BUN: 36 mg/dL
BUN: 8-18 mg/dL
Creatinine serum: 1.27 mg/dL
Creatinine serum: 0.6-1.2 mg/dL
Calcium: 8.4 mg/dL
Calcium: 9-11 mg/dL
Protein, total: 5.8 g/dL
Protein, total: 6-8 g/dL
Albumin: 1.8 g/dL
Albumin: 3.5-5 g/dL
Prealbumin: 9 g/dL
Prealbumin: 16-35 g/dL
C-reactive protein: 2.4 mg/dL
C-reactive protein: <1.0 mg/dL
Cholesterol: 92 mg/dL
Cholesterol: 120-199 mg/dL


Coagulation (Coag)
Coagulation (Coag)
PT: 15.1 sec
PT: 12.4-14.4 sec


Hematology
Hematology
RBC: 2.4 x103/mm3
RBC: 4.5-6.2 x103/mm3
Hemoglobin: 8.1 g/dL
Hemoglobin: 14-17 g/dL
Hematocrit: 24.1%
Hematocrit: 40-54%
Mean cell volume: 100.6 mcm3
Mean cell volume: 80-96 mcm3
Mean cell Hgb: 33.6 pg
Mean cell Hgb: 26-32 pg
RBC distribution: 18%
RBC distribution: 11.6-16.5%


Hematology, Manual Diff
Hematology, Manual Diff
Lymphocyte: 11%
Lymphocyte: 15-45%


Urinalysis
Urinalysis
Specific Gravity: 1.033
Specific Gravity: 1.003-1.030
pH: 7.0
pH: 5-7
Ketones: +
Ketones: -
Urobilinogen: 0.2 EU/dL
Urobilinogen: <1.1 EU/dL
Prot chk: +
Prot chk: -
Bact: +
Bact: 0
Interpretation and/or Comments: Lab values show high levels of sodium, chloride, BUN, and
creatinine, which may be due to dehydration. Total protein, prealbumin, and albumin are below reference
value, which may be due to malnutrition. Ketones present in urine due to ketosis means that patient is
malnourished and is burning fat. High MCV may be due to excessive alcohol consumption, deficiency in
Vitamin B12, or deficiency in folate.

4. Nutrition-Focused Physical Findings
This pt/ client
Expected or normal
Cachetic, appears older than years
Appears to look within age
Head: noted temporal wasting
No temporal wasting
Extremities: decreased muscle tone ROM; loss of
No decreased muscle tone
lean mass noted quadriceps and gastrocnemius; 1+
pedal edema
No edema
Skin: warm and dry with ecchymoses
Warm with no ecchymoses

Interpretation and/or Comments: Nutrition-focused physical findings exhibits indication of moderately
to severely malnourished.

Updated 1/2015, Long Wang

5.

Client history
Client History

Implications on Nutrition Care

Personal: 68 y/o Caucasian male


Patient is older, which is a risk factor of CVD and


malnutrition. Impaired olfaction, which affects taste and
smell of food, can be due to aging (Brown, Isaacs,
Krinke, Lechtenberg, Murtaugh, Sharbaugh, Splett, &
Stang, 2011, p. 461).

Years Education: 9 years


Additional education regarding treatment for


malnutrition, oral cancer, and CVD will be required for
this patient.

Social: Married lives with wife


Patient will have to shop for, prepare, and cook his food
with his wife or his wife will be his caretaker. Education
to his wife will also be needed.

Tobacco use: 1 ppd for 60+ years


Smoking is a risk factor for CVD and oral cancer.


Alcohol use: 1-3 cans of beer/day


Use of alcohol increases the risk of hypoglycemia. The


medications the patient is on should not be mixed with
alcohol; it can cause side effects or can prevent
medication from working.

Chief Complaint: generalized weakness;


admitted to acute care for possible
dehydration, weight loss, generalized
weakness, and malnutrition

Patient will need to increase fluid and food intake.


Hunger and thirst signals are weaker in older adults.
Older adults may need to be more conscious of food
intake levels because their appetite-regulating
mechanisms may not be sharp (Brown et al., 2011, p.
462). Dehydration occurs more quickly after fluid
deprivation and that rehydration is less effective in older
men (Brown et al., 2011, p. 462).

Diagnosed 5 years ago w/ squamous cell


carcinoma of tongue; pt previously
treated w/ radiation therapy no
treatment x3 years

Patient was diagnosed with oral squamous cell carcinoma


of tongue, which can decrease oral intake during
radiation therapy. Also, patient has been noncompliant
with radiation therapy for 3 years.

Occupation: Retired meat cutter


Family History: Mother died of


pneumonia; father died of lung cancer

Patient is genetically predisposed to lung sensitivity.

Physical Activity: N/A


Physical inactivity is a risk factor for HTN and


hyperlipidemia. Patient is underweight and physical
activity and weight gain could improve his conditions.

Updated 1/2015, Long Wang

Medication:
Lipitor 80mg daily
Capoten 25mg 2x/day

New medication order:
Thiamin injection 100 mg/day
Multivitamin capsule 1 Cap/day
Metronidazole 500 mg in NaCl
premix IVPB
Docusate capsule 100 mg 2x/day
Lipitor 80 mg daily
Lopressor 5 mg every 6 hours

Lipitor A statin (HMG CoA inhibitor) that reduces


production levels of LDL cholesterol and triglycerides,
while increasing HDL levels.
Chol, LDL, TG, VLDL, apoB, HDL,
CRP, AST, ALT, alk phos, Transient CPK,
CoQ10, rare: dyscrasias, myoglobin
Dietary fat and cholesterol, Ca if needed,
avoid citrus foods, avoid alcohol
Capoten An ACE inhibitor that relaxes the blood
vessels so blood can flow more easily; therefore this drug
treats HTN.
K, Na, AST, ALT, alk phos, bil, anemia,
WBC. Transient BUN, crea.
May cause dizziness, headache, fatigue, muscle
pain, insomnia.
Avoid salt subs, licorice, alcohol. Caution with K
supplements.
Caution with geriatric.

Docusate stool softener, laxative that requires high
fiber diet with 1500-2000 mL fluid/day to prevent
constipation.
glucose, K
Lopressor antihypertensive medication that treats high
BP by blocking the effects of epinephrine and slowing
down heart rate, thus decreasing the hearts demand for
oxygen.
Rare- AST, ALT, alk phos, LDH, K, TG,
uric acid
Avoid natural licorice

Surgical History: s/p partial glossectomy


5 yrs ago

Glossectomy may interfere with eating pattern and


choices of foods consumed. An individual may have
swallowing dysfunctions after oral resection; a degree of
dysphagia will be present in patient (Priya, Menon, Iyer,
& Thankappan, 2013).

Updated 1/2015, Long Wang

Part Two: Nutrition Diagnosis



Intake
Clinical
Behavioral-Environmental
Too much or too little of a food
Nutrition problems that relate to Knowledge, attitude, beliefs,
or nutrient compared to actual
medical or physical conditions
physical environments, access to
or estimated needs
food, or food safety
A. Analyze the assessment data collected in light of the patients admission medical diagnosis or
reason for referral. What was normal? What was not normal?
Normal: Vital signs indicated temperature of 96.6 degrees Fahrenheit, pulse of 101, and respiratory
rate of 20. Patient also had a normal blood pressure of 122/77 with a BMI of 19.5 lb/in2. Normal heart
rate and rhythm, eyes, ears, dry mucous membranes without exudates or lesions in the throat. Patient
is alert and oriented.
Abnormal: Physical examination exhibited dry mucous membranes with petechiae in the nose,
decreased muscle tone with normal ROM, loss of lean mass noted in quadriceps and gastrocnemius,
1+ pedal edema. Patients skin is warm and dry with ecchymoses. Dietary recall indicated energy
intake of 789 kcal and fluid intake of 840 mL/day. Clients history indicated alcohol consumption of
1-3 beers/day and tobacco use of 1 ppd/day for 60+ years. Patients laboratory values indicated
elevated sodium (150 mEq/L), chloride (118 mEq/L), BUN (36 mg/dL), creatinine serum (1.27
mg/dL), MCV (100.6 m3), mean cell hemoglobin (33.6 pg), and RBC distribution (18%). In
addition, patients potassium (3.4 mEq/L), calcium (8.4 mg/dl), total protein (5.8 g/dL), albumin (1.8
g/dl), prealbumin (9 mg/dl), cholesterol (92 mg/dl), RBC (2.4x 103mm3), hemoglobin (8.1 g/dL),
hematocrit (4.1%), and lymphocyte (11%) levels are low. Ketones, blood, and bacteria are also
positive in patients urinalysis.

B. Is this a well-nourished patient? Why or why not?
No, this patient has an SGA rating of C, moderately malnourished. There are several physical
markers, diet and related history evidence, and biochemical data showing that he is malnourished.
Upon admission, he was diagnosed with dehydration, generalized weakness, weight loss, and
malnutrition. Physical examination shows a presence of temporal wasting and 1+ edema which are
signs of protein inadequacy, indication of low platelet count or Vitamin C and/or K deficiency, and
malnutrition (White et al., 2015) respectively. Patient has a BMI of 19.5 lb/in2, placing him at
heightened risk for loss of lean muscle mass for his age. Lab value shows CRP level above normal; an
indication of inflammatory response, which could be indicative of malnourishment related to chronic
disease.

C. Is the patients current oral nutrient intake or nutrition support meeting his/her nutritional
needs?
No, this patients current oral nutrient intake is well below expected required intake (an average of
789 kcal/day). Patient is deficient in kcal, Vitamin K, Folate, Vitamin C, and Vitamin E resulting
from low energy intake and limited intake of fruits and vegetables. He has reported to have lost 60 lbs
over a 1-2-year period and was admitted with diagnosis of malnutrition. Diet recall indicates he is
receiving little to no micronutrients and cannot consume more than Ensure at one time.

D. Are there any other indications of nutrition problems?
Yes, patient reports weakness and little to no appetite. He was diagnosed with squamous cell
carcinoma and received chemotherapy treatment, which may affect his ability to eat and may have
altered his sense of taste. A decrease in sense of taste is common side effect of 30-70% of
chemotherapy recipients (Kano, Kanda, 2013). Due to his partial glossectomy, he cannot tolerate
Updated 1/2015, Long Wang

specific textures of food. There were signs of impaired neurological strength; another criteria for the
diagnosis of malnutrition.

Problem:
Potential nutrition problems using NCP terminology:
Inadequate fluid intake NI-3.1
Unintended weight loss NC-3.2
Inadequate protein intake NI-5.7.1
Inadequate protein-energy intake NI-5.3
Inadequate oral intake NI-2.1
Malnutrition NI-5.2
Chronic disease or condition related malnutrition NI-5.2.2
Inadequate energy intake NI-1.2
Involuntary weight loss
Swallowing difficulty NC-1.1
Biting/chewing (masticatory) difficulty NC-1.2

Etiology: What caused or contributed to these problems?
Potential causes using NCP terminology:
Inability to manage self-care NB-2.3
Poor nutrition quality of life NB-2.5
Limited adherence to nutrition-related recommendations NB-1.6

Signs and symptoms: What evidence shows that there is a problem? How do you know there is a
problem? These are also your monitoring and evaluation parameters.
Anthropometric measurements: 70.9% UBW and lost 29% UBW over the past 2 years.
Nutrition Related Physical Findings: Exhibits temporal wasting, reduced strength, decreased muscle
tone, quadriceps and gastrocnemius: loss of lean mass, 1+ Pedal edema, and Hypoactive bowel sounds.
Food/Nutrition Related History: Consumes on average 789 kcal/day when needs are at 2130 kcal/day.
He reports feeling satiated prematurely and lack of appetite related to cancer treatments for primary
tongue squamous cell carcinoma. Patient was prescribed a mechanical soft diet.
Client History: Smokes 1ppd for 60+ years and drinks 1-3 cans of beer/day which may cause olfactory
impairment (loss of taste and smell). He has had partial glossectomy which may interfere with ability to
chew/move food around in mouth.
Biochemical data, medical tests, and procedures: Ketones positive while patient does not have diabetes
may be symptom of muscle wasting. Lab values of total protein 5.8, albumin 1.8, prealbumin 9 resulting
from limited energy intake.

PES Statement 1
Problem

Inadequate oral intake

R/T

Etiology

tongue cancer with presence of petechiae and radiation


therapy treatment

AEB

Sign and Symptoms




pt reported of being full quickly due to radiation therapy,


diet recall of 789 kcal/day compared to his recommended
intake of 2130 kcal/day (30 kcal/kg), noted temporal
wasting, and unintended weight loss with UBW of 220lb

Updated 1/2015, Long Wang

and CBW of 160lb (60 lbs. lost within the last 2 years).
PES Statement 2
Problem

Malnutrition NI-5.2

R/T

Etiology

Inability to manage self-care

AEB

Sign and Symptoms





diet recall of 789 kcal/day compared to the recommended


2130 kcal/day, unintended weight loss of 60 lbs, and
generalized fluid accumulation (pedal edema).

Updated 1/2015, Long Wang

Part Three: Nutrition Intervention



Nutrition Prescription (Nutrition Rx):
Specific diet (if applicable)
Puree diet w/ medical food supplement

Energy goal (Kcal/day)
1775 kcal/day
(start patient at 1775 kcal/day and increase to

2130 kcal/day if tolerated)
Protein goal (g/day)
85 g/day (1.2 g/kg)

If there is any specific goal or restrictions, please
list below
Restrict alcohol consumption to 1 can/day and reduce Increase fluid intake to 2130 mL/day
to 0 cans/day if possible
Restrict tobacco use to ppd and reduce to 0 ppd if
Increase protein intake to 85 g/day
possible
Add 1-2 servings of colorful fruits
Increase carbohydrate intake to 200-288
g/day with 25 g of fiber
Add 1-2 servings of colorful vegetables
Increase:
Vitamin C: >75 mg/day
Vitamin E: 15 mg/day
Vitamin K: 90-120 mcg/day
Folate: ~320 mcg/day

Strategic goals of nutrition intervention:
Due to <5%PO on mechanical soft diet, patient will be advance to puree diet with energy intake of 1775
kcal/day, increasing macronutrients as well as micronutrients as tolerated. Patient will consume 5 small
meals throughout the day and try different flavors and forms of Ensure, such as butter pecan or chocolate
pudding, to meet nutritional needs. Ask patient what he enjoys eating and what is his favorite food. May
need to request MD to order appetite stimulant medications if patient does not improve intake (Rudolph,
2009). 2 fish oil capsules (containing 1.32gm omega-es/capsule, 1.1g EPA/capsule, 0.31g DHA/capsule)
per day will be added to diet to increase lean mass (Luis et al., 2005).

Food and/or nutrient
Nutrition Education
Nutrition Counseling Coordination of
delivery
Nutrition Care
An individualized
A formal process to
A supportive process,
Consultation with,
approach for
instruct or train a
characterized by a
referral to, or
food/nutrient provision, pt/client in a skill or to collaborative
coordination of
including meals and
impart knowledge to
counselor-patient
nutrition care with
snacks, enteral and
help pts/clients
relationship, to set
other healthcare
parenteral nutrition,
voluntarily manage or
priorities, establish
providers, institutions,
and supplements
modify food choices
goals, and create
or agencies that can
and eating behavior to
individualized action
assist in treating or
maintain or improve
plans that acknowledge managing nutritionhealth
and foster
related problems.
responsibility for selfcare to treat an existing
condition and promote
health
Updated 1/2015, Long Wang


Please summarize the relevant evidence regarding nutrition therapy of the disease conditions.
Please indicate the source of the evidence.
The EAL recommends RDs to use medical food supplements to help enhance the protein and energy
status of oncology patients who suffer from head or neck cancers (including oral), as these patients are
prone to malnutrition. Providing medical food supplements has shown to reduce risk of weight loss and
risk of mucosal damage. Furthermore, it is considered a grade 1 recommendation to provide a medical
food supplement containing fish oil as it has been shown to increase lean mass in oncology patients
(EAL). Protein needs for those who have head and neck cancers who have undergone radiation therapy
are significantly higher than that of the RDA for those of their weight (EAL).

Describe the nutrition intervention using approved NCP terminology (eNCPT).
Food and/or nutrient delivery: Modify composition of meals and snacks. (ND-1.2)
It has been determined that the patient would benefit from a puree diet due to prior glossectomy, which
may interfere with ability to chew/move food around in mouth. Patient will receive 5 small meals
throughout the day and 2 fish oil capsules to help increase lean body mass. Medical food supplements,
such as Ensure, in different flavors and forms will be given to patient to increase energy intake to treat
malnutrition. A diet plan has been formulated to increase energy, carbohydrate, protein, fat, vitamins, and
minerals intake and to inhibit the presence of ketones in the urine. This diet plan will also increase fluid
intake to meet nutritional requirements and improve lab results. If lab results of sodium, chloride, BUN,
and creatinine does not improve from hydration, another intervention will be needed to address those
issues. An appetite stimulant may be requested from MD if dietary intake does not improve.

Nutrition Education: Nutrition relationship to health/disease. (E-1.4)
Nutrition education is provided to patient and patients wife about malnutrition, which may be due to
radiation therapy patient received 3 years prior. Inform patient that muscle wasting correlates with low
levels of physical activity and food intake along with age-associated physiological changes, and lean body
mass is imperative in geriatrics (Brown et al., 2011, p. 459-460). Educate them on various medical food
supplements and other ways in consuming these supplements will become more appealing to patient
(milkshake, smoothie, and pudding). Providing handouts and web addresses about malnutrition after a
glossectomy and in geriatrics may be helpful in getting started and making it easier to understand what
needs to be done nutritionally. Lastly, educate them on Docusate; patient will need to be on a high fiber
diet with 1500-2000 mL fluid/day to prevent constipation.

One-day sample menu: Please refer to Appendix B for one-day sample menu.

Dietary analysis of the sample menu: Please refer to Appendix C for dietary analysis of the sample
menu.


Updated 1/2015, Long Wang

Part Four: Nutrition Monitoring and Evaluation



Food/NutritionRelated History
Outcomes
Food and nutrient
intake,
medication/herbal
supplement intake,
knowledge, beliefs,
food and supplies
availability, physical
activity, nutrition
quality of life

M/E
1
2
3
4
5
6
7
8
9
10

M/E

Biochemical Data,
Medical Tests, and
Procedure Outcomes
Lab data (e.g.
electrolytes, glucose)
and tests (e.g. gastric
emptying time, resting
metabolic rate)

Anthropometric
Measurement
Outcomes
Height, weight, body
mass index (BMI),
growth pattern
indices/percentile
ranks, and weight
history

Nutrition-Focused
Physical Assessment
Outcomes
Physical appearance,
muscle and fat wasting,
swallow function,
appetite, and affect


Food/Nutrition-Related History Outcomes

NCP Terminology
Additional Notes if Applicable
Energy intake (1.1.1) Total energy
Recommended intake: 1775 kcal/day
intake
Fluid/beverage intake (1.2.1) Oral fluids Recommended intake: 2130 mL/kg
Fluid/beverage intake (1.2.1) Liquid
Recommended intake: 1 can Ensure/day
meal replacement or supplement
Food intake (1.2.2) Types of food/meals Recommended intake: puree foods with medical
nutrition supplements
Alcohol intake (1.4.1) Frequency
Recommended intake: 1 can of beer or less/day
Vitamin intake (1.6.1) C
Recommended intake: >75 mg/day
Vitamin intake (1.6.1) E
Recommended intake: 15 mg/day
Vitamin intake (1.6.1) K
Recommended intake: 90-120 mcg/day
Vitamin intake (1.6.1) Folate
Recommended intake: ~320 mg/day
Protein intake (1.5.2)
Recommended Intake : 85 g/day (1.2-1.5g/kg)

Biochemical Data, Medical Tests, and Procedure Outcomes

NCP Terminology
Additional Notes if Applicable

Electrolyte and renal profile (1.2) BUN

Achieve desirable range of 8-18 mg/dL

Electrolyte and renal profile (1.2)


Creatinine

Achieve desirable range of 0.6-1.2 mg/dL


Electrolyte and renal profile (1.2)


Sodium

Achieve desirable range of 136-145 mEq/L


Electrolyte and renal profile (1.2)


Chloride

Achieve desirable range of 95-105 mEq/L


Updated 1/2015, Long Wang

Lipid profile (1.7) Cholesterol, serum

Achieve desirable range of 120-199 mg/dL

Electrolyte and renal profile (1.2)


Potassium

Achieve desirable range of 3.5-5.5 mEq/L


Inflammatory profile (1.6) C-reactive


protein

Achieve desirable range of <1.4 mg/dL

Nutritional anemia profile (1.10)


Hemoglobin

Achieve desirable range of 14-17 g/dL

Nutritional anemia profile (1.10)


Hematocrit

Achieve desirable range of 40-54%

10

Nutritional anemia profile (1.10) Red


cell distribution width

M/E
1
2
3


Anthropometric Measurement Outcomes

NCP Terminology
Additional Notes if Applicable
Body composition/growth/weight
Achieve IBW of 196 lbs
history (1.1) Weight
Body composition/growth/weight
Achieve IBW
history (1.1) Weight change
Body composition/growth/weight
Achieve desirable BMI for age of 25-30 lb/in2
history (1.1) Body mass index

M/E
1
2
3

4
5


Nutrition-Focused Physical Assessment Outcomes

NCP Terminology
Additional Notes if Applicable
Nutrition-focused physical findings
Look for appearance of muscle and weight gain
(1.1) Overall appearance: cachetic
Nutrition-focused physical findings
Aim to increase energy and lessen overall feelings of
(1.1) Overall appearance
tiredness
Nutrition-focused physical findings
Increase muscle tone by reaching healthy weight and
(1.1) Extremities, muscles and bones:
BMI of 25-30 lb/in2
loss of muscle mass in quadriceps and
gastrocnemius
Nutrition-focused physical findings
Decrease temporal wasting and increase protein
(1.1) Head and eyes: noted temporal
consumption
wasting
Nutrition-focused physical findings
Maintain normal skin temperature but reduce
(1.1) Skin: ecchymoses
presence of ecchymoses

Updated 1/2015, Long Wang

ADIME Note - Initial Assessment

Assessment
Chief complaint: generalized weakness; admitted to acute care for possible dehydration, wt. loss, generalized
weakness, and malnutrition
Personal Hx: 68 yo Gender: Male Medical Hx: diagnosed with squamous cell carcinoma of the tongue 5 years ago
and was treated with radiation therapy approx. 3 years ago. Hypertension, hyperlipidemia, weight loss,
peripheral vascular disease. Lipitor 80mg/d, Capoten 25mg 2x/d
2
Anthropometrics: ht: 63 (75 in), wt: 156lb (71 kg), BMI: 19.5 kg/m , IBW: 196 lb (89 kg)
Biochemical data: Sodium 150 mEq/L, MCV, Chloride 118 mEq/L, BUN 36 MG/dL, Calcium 8.4 mg/dL,
3
3
Albumin 1.8 g/dL, Prealbumin 9 g/dL, CRP 2.4 mg/dL, Cholesterol 205 mg/dL, RBC 2.4x10 /mm ,
Ketones +, Hemoglobin 8.1 d/dL.
Macronutrient intake/day: 789 kcal, 103 g CHO (52%), 68 g pro, 38 g fat (43%)
Medication Rx: 0.9 sodium chloride with potassium chloride 20 mEq 125 mL/hr, Thiamin injection 100 mg/d,
Multivitamin capsule 1 Cap/d, Docusate capsule 100 mg 2x/d, Lipitor 80 mg/d, Lopressor 5 mg/6 hrs.
Diet: prescribed a mechanical soft diet, <5% PO, states that he gets full really easily and never feels hungry.

Diagnosis
1. Inadequate oral intake R/T tongue cancer with presence of petechiae and radiation therapy treatment AEB pt
reported of being full quickly due to radiation therapy, diet recall of 789 kcal/d compared to his recommended
intake of 1775 kcal/d (25 kcal/kg), noted temporal wasting, and UBW of 220lb and CBW of 160lb (60 lbs lost
within the last 2 years).
2. Malnutrition R/T inability to manage self-care AEB diet recall of 789 kcal/d compared to the recommended
1775 kcal/d, unintended weight loss of 60 lbs, and generalized fluid accumulation (pedal edema).

Intervention
Nutrition Rx: 1775 kcal, 85 g PRO, 200-288 g CHO (45-65%), 25 g Fiber, 39-69 g Fat (20-35%), 2130 mL fluid,
Vitamin C >75 mg, Vitamin E 15 mg, Folate ~320 mg, Vitamin K 90-120 mcg.
Food and Nutrient Delivery: Modify Composition of Meals and Snacks (ND-1.2) Request for puree diet and
incorporate medical food supplements to increase total energy intake to 1775 kcal/d. Increase fluid intake to
2130 mL/d (30 mL/kg). Small meals throughout the day w/ snacks 2x/d. Asked patient what types of
food/drinks does he prefer. 2 fish oil capsule to increase LBM. May request appetite stimulant from MD if
intake does not improve.
Nutrition Education: Nutrition Relationship to Health/Disease (E-1.4) Informed patient and wife on factors
relating to malnutrition and how to prevent malnutrition by changes in diet and use of medical food
supplements. Handouts and websites offered to patient. Informed patient high fiber diet required for Docusate.
Goals:
1. Patient will increase energy intake to 1775 kcal/d with various nutrient-dense foods provided on 1-day sample
menu. Increase to 2130 kcal/d if tolerated.
2. Patient will increase fluid intake to 2130 mL/d by consuming water, milk, juice, broth, and Ensure.

Monitoring and Evaluation


1. Food and Nutrient Intake: Total Energy Intake (1.1.1) - Adherence to recommended changes in diet.
2. Nutrition-focused physical findings (1.1) Overall appearance: Assess weight, presence of edema, and signs of
muscle wasting.
3. Biochemical Data, Medical Tests and Procedures: CRP, albumin, prealbumin, ketones - Achieve reference
range.

Updated 1/2015, Long Wang

Jessica Lamons 9/23/15 1100


Jessica Lopez 9/23/15 1100
Jenny Nguyen 9/23/15 1100
Gisela Garcia 9/23/15 1100
Samara Heller 9/23/15 1100


References Cited in this Worksheet
Brown, J.E., Isaacs, J., Krinke, B.U., Lechtenberg, E., Murtaugh, M.A., Sharbaugh, C., Splett, P.L., &
Stang, J. (2011). Nutrition Through the Life Cycle: Nutrition and Older Adults (4th ed.). Belmont:
Wadsworth, Cengage Learning.
DeLuis, D., Izaola, O., Aller, R., Cuella, L., Terroba, M., A Randomized Clinical Trial with Oral
Immunonutrition (omega 3-enhanced formula vs. arginine-enhanced formula) in ambulatory head
and neck cancer patients. Annals of Nutrition and Metabolism. Retrieved from
http://222.andeal.org
Kano, T., Kanda, K. (2013). Development and Validation of a Chemotherapy-Induced Taste Alteration
Scale. Oncology Nursing Forum, 40(2), E79.
Mutsumi, O. (2007). Reconstruction with Rectus Abdominis Myocutaneous Flap for Total Glossectomy
with Laryngectomy. Journal Of Reconstructive Microsurgery, 23(5), 243-249.
Priya, M., Menon, R. J., Iyer, S., & Thankappan, K. (2013). OP076: Videoflouroscopic evaluation of
swallowing after glossectomy A prospective study. Oral Oncology, 49, 34.
doi:10.1016/j.oraloncology.2013.03.084
White, J., Guenter, P., Jensen, G., Malone A., & Schofield, M. (2012). Consensus Statement of the
Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition:
Characteristics Recommended for the Identification and Documentation Of Adult Malnutrition
(Undernutrition). Journal of the Academy of Nutrition and Dietetics, 112(5), 730-738.
doi:10.1016/j.jand.2012.03.012


Updated 1/2015, Long Wang


Appendices

Appendix A. Intake analysis using Food Processor software (installed in FCS computer labs).
a. Spreadsheet



Updated 1/2015, Long Wang


b. Bar graphs

Updated 1/2015, Long Wang



















Updated 1/2015, Long Wang

c. Pie chart for macronutrient distribution













Updated 1/2015, Long Wang

d. MyPlate recommendation

Updated 1/2015, Long Wang


Appendix B. Nutrition Intervention: sample menu for one-day.

Breakfast:
2 Scrambled Eggs + tbsp Unsalted Butter + Pinch of Mrs. Dash Seasoning
6 oz Pancake Slurry
8 oz Oatmeal + Small Pureed Banana
8 oz Coffee + 1 Half and Half

AM Snack:
Chocolate Strawberry Milkshake (4 oz Chocolate Ensure plus + 2 oz Strawberries)
8 oz Water

Lunch:
4 oz Pureed Roasted Chicken
4 oz Pureed Spinach
4 oz Pureed Sweet Potatoes
2 tsp Unsalted Butter
6 oz Pureed Split Pea Soup
4 oz Orange Juice (to enhance protein absorption)

PM Snack:
Fruit and Cottage Cheese Plate (4 oz Cottage Cheese + 4 oz Pureed Fruit Cocktail)
4 oz Coconut Water
4 oz Water

Dinner:
4 oz Pureed Enriched Pasta
2 Pureed Meatballs
4 oz Marinara Sauce
8 oz Pureed Cauliflower, Broccoli, Zucchini Blend
2 tsp Unsalted Butter
8 oz Water ( squeezed lemon + 1 mint leaf)

Dessert:
2 oz Vanilla Greek Yogurt + 1 tbsp Crushed Walnuts + tsp Cinnamon
4 oz Water
4 oz Butter Pecan Ensure Plus


Updated 1/2015, Long Wang


Appendix C. Analysis of the sample menu using Food Processor software.

e. Spreadsheet

Updated 1/2015, Long Wang























Updated 1/2015, Long Wang

f.

Bar graphs

Updated 1/2015, Long Wang



















Updated 1/2015, Long Wang

g. Pie chart for macronutrient distribution













Updated 1/2015, Long Wang

h. MyPlate recommendation

Updated 1/2015, Long Wang