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Running Head: CANCER NCP

Theresa Price Cancer NCP The University of Southern Mississippi

CANCER NCP Section 1: Chart Note SCRMC CLINICAL NUTRITION SERVICES NUTRITIONAL ASSESSMENT Patient information: Pt is a 61 y.o. white female admitted with abdominal pain and nausea. Pt has had a very poor appetite and was diagnosed with cancer that had metastasized from previous Breast Cancer. Pt had a gastric tumor that was perforated. Pt also had pneumoperitoneum and a NG tube was placed for suctioning. Pt is a regular smoker and does not report ETOH use. PICC line was placed to initiate TPN. PMH: Breast cancer, HTN, and Peptic Ulcer Disease. Reason for RD consult: Low albumin level of 2.3 and TPN initiation. Current Diet Order: NPO, TPN initated with standard formula of 20% fat emulsion at 10ml/hr, Amino Acids of 4.25% and Dextrose of 25% at 50ml/hr (1704kcal and 51g pro). Supplements: N/A at this time. Wt: 211lb Ht: 66in IBW: 130lb %IBW: 162% BMI: 34 ABW: 150lb Nutritional Needs: Energy: 2218kcal (calculated with Mifflin St. Jeor with 1.2 AF and 1.2 IF) Protein: 68-81g (1.2-1.5g/mg) Fluid:2218ml Labs: High:Glucose-120(non Diabetic), WBC-14 Low: RBC-3.17, Hgb-10.21, HCT-30.7, Albumin-2.3 Pertinent medications: Hyoscyamine, Novalin R Insulin per Sliding Scale, Hydralazine, Lotrel, Protonix, Invanz, and Phenergan. Nutritional Diagnosis: 1. Increased nutrient needs RT present Cancer and increased demand for surgical incision healing AEB findings of metastasized cancer and low albumin level of 2.3.

CANCER NCP

2. Inadequate parenteral nutrition infusion RT physiological causes increasing nutrient needs (i.e. Cancer and post surgery wound) AEB infusion volume at lower end of energy needs and protein needs not being met and low albumin status of 2.3. Recommendations/Plan of care: Recommend increasing TPN rate to Lipids at 20% with a rate of 8ml/hr, Dextrose 25% and Amino Acids 4.25% at 70ml/hr. This TPN provides 2098kcal and 71.4g Protein. Changing the TPN rate increases calories and protein to recommended needs. Will monitor/evaluate: Will monitor TPN rate and albumin status. Will make nutritional recommendations at follow up and as necessary.

CANCER NCP Section 2: Structured Abstract Citation: Bozzetti, F., Gianotti, L., Braga, M., Di Carlo, V., & Mariani, L. (2007). Postoperative complications in gastrointestinal cancer patients: The joint role of the nutritional status and the nutritional support. Clinical Nutrition, 26, 698-709. doi: 10.1016/j.clnu.2007.06.009 Study Design: Class: Quality Rating: Research Purpose: The study design was a nonrandomized trial with historical controls. This study is a class C report. No quality rating was determined. The purpose of this study was to determine if there were postoperative complications associated with nutritional status and alternative nutrition feeding. The inclusion criteria for participation included patients of a previous randomized clinical trial, had gastrointestinal cancer, and received some form of nutritional support. The exclusion criteria for the study included patients who had abnormal functioning organs, or received heavy treatments of steroids or immunosuppressant medicines. Recruited participants signed a written consent form and baseline measurements were collected. After surgery, patients were given one of two enteral nutrition (EN or IEEN) feedings, parenteral nutrition (TPN), or a standard intravenous fluid (SIF) until patients diet was advanced as tolerated. After hospital discharge the participants were evaluated for any postoperative complications such as infection, respiratory failure, renal issues, and delayed gastric emptying 30 days later. Baseline measurements such as weight loss, hemoglobin, and albumin were collected as the main data collection. Complications between the different nutrition feedings were also collected. There was no blinding used in this study.

Inclusion Criteria:

Exclusion Criteria:

Description of Study Protocol

Data Collection Summary:

CANCER NCP Description of Actual Data Sample: There were a total of 1410 participants in the study. There were patients given parenteral nutrition and 893 were given one of two forms of enteral nutrition. The participants had gastrointestinal cancer that ranged from the colon, stomach, or the pancreas. Baseline measurements included weight, any weight loss, hemoglobin, albumin, lymphocyte count, type of surgery, operative blood loss, and any blood transfusions. Follow up for any infections were completed 30 days after discharge. Summary of Results The parenteral nutrition group had 308 patients experience 10% or more weight loss, the enteral nutrition group had 451 experience 10% or more weight loss. Between the four types of nutrition there was significant imbalance of weight loss (p<0.001), hemoglobin level (p=0.049), lymphocyte count (p=0.016), and albumin (p<0.001). Malnutrition due to weight loss was most evident in EN or TPN, long surgical procedure occurred more within TPN and both enteral nutrition groups. Out of all the postoperative complications 7% were considered major and 32% were considered minor, and death occurred in 26 participants. The type of nutrition feeding was significantly related to the postoperative risks (p<0.001). Weight loss (p=0.019), albumin (p=0.019), and nutrition support (p=0.001) related to postoperative complications. Parenteral nutrition support participants experienced 54 minor complications and 34 major complications. There were 97 infectious complications associated with the parenteral nutrition group and 101 noninfectious complications. The enteral nutrition support patients experienced 166 minor complications and 46 major complications. There were 144 infectious complications with the enteral nutriton support patients and 219 noninfectious complications. Postoperative complications are more severely affected by age, type of surgery, albumin compared to the nutritional status. When a patient experiences malnutrition due to weight loss may be a risk factor for postoperative morbidity. Nutrition support indicated benefits for all participants in the study, and mostly patients with 10% or more weight loss. Alternative feeding also may lower the risk of infectious postoperative complications compared to noninfectious complications. Nutrition support may be limited in providing reduced risk for postoperative complications. This study utilized a large sample size, which is a strength,

Author Conclusion:

Review Comments:

CANCER NCP but is not large enough to be generalized to the population, which is a limitation. A strength of this study was that the author used a variety of resources for the literature review and references to compare the study results to. A limitation of the study was noted within the discussion of the article, the author used the word proved instead of indicated when discussing nutrition support in surgical patients.

CANCER NCP Section 3: EAL and Article Summary for My Patient Literature suggests patients with gastrointestinal cancers may benefit from nutrition support after surgical procedures (Bozzetti, Gianotti, Braga, Di Carlo, & Mariani, 2007). The research conducted by Bozzetti and colleagues (2007) was conducted among over 1,000 gastrointestinal cancer patient to determine if their nutritional status and nutrition support were

factors with postoperative risks. The study indicated non-nutritional aspects such as age, type of surgery, and serum albumin levels affect the postoperative risks such as infections more than the nutritional aspects. However, the nutrition variables studied showed that patients who were not experiencing malnourishment due to 10% or more weight loss and who were receiving nutrition support had less postoperative risks. The Evidence Analysis Library (EAL) conclusion statement concluded that parenteral nutrition helped maintain nutritional status in nourished breast cancer patients (Roberts, Miller, Pineriro, & Jennings, 2003). I recommend continuing the total parenteral nutrition (TPN) infusion in order to reduce postoperative risks such as infection from gastric cancer removal surgery and to preserve nutritional status since my patient also has breast cancer.

CANCER NCP References Bozzetti, F., Gianotti, L., Braga, M., Di Carlo, V., & Mariani, L. (2007). Postoperative complications in gastrointestinal cancer patients: The joint role of the nutritional status and the nutritional support. Clinical Nutrition, 26, 698-709. doi: 10.1016/j.clnu.2007.06.009 Roberts, S., Miller, J., Pineriro, L., & Jennings, L. (2003). Total parenteral nutrition vs oral diet

in autologous hematopoietic cell transplant recipients. Bone Marrow Transplantation, 32, 715-721. doi: 10.1038/st.bmt.170424