Introduction:

This paper will look at the Nutrition Care Process involved in a head and neck cancer patient.
Mr. T is a fifty one year old Caucasian male who is currently living back and forth between a
friends apartment and a local shelter. He is originally from another state in the south and does
not have family in Montana. His past medical history includes a seizure disorder due to alcohol
withdrawals, stroke, chronic obstructive pulmonary disorder, hypertension, and anxiety. Mr. T
admits to being a previous heroin user, uses tobacco and is an alcoholic.
He was diagnosed with squamous cell carcinoma in in the soft pallet and tongue moving into the
esophagus on September 9th 2016. Once diagnosed he was admitted to the hospital and his teeth
on the right side of the jaw were removed before starting radiation on the mouth. Mr. T was also
diagnosed with dysphagia from painful swallowing and malnutrition with a BMI of 17.6.
Pathophysiology:
Mr. T was diagnosed with squamous cell carcinoma which is commonly caused by exposure to
carcinogens such as tobacco and alcohol and potentially human papilloma virus (Athanassios).
Squamous cell carcinoma is a cancer that arises from cells called squamous cells found in the
outer layer of skin and in the mucous membranes. Head and neck squamous cell carcinoma,
HNSCC, develops in the mucous membranes of the mouth, nose, and throat. Depending on the
location, the cancer can cause rough patches or ulcers in the mouth and throat, unusual bleeding
or pain in the mouth, sinus congestion, sore throat, earache, painful or difficulty swallowing, a
hoarse voice, difficulty breathing, or enlarged lymph nodes. HNSCC can metastasize to other
parts of the body, such as the lymph nodes or lungs which can be fatal (Head and Neck
Squamous Cell Carcinoma).
Nutrition Care Process
Assessment:
Although Mr. T has no dietary restrictions related to his beliefs, his intake was largely dependent
on what was available at the shelter, how much money he had and what his friend was making.
He did not have ready access to food but consumed beer all day long, and had very little
knowledge about what foods were healthy or unhealthy. Once admitted Mr. T ate as well as his
oral pain would allow, usually three small meals a day and one to two liters of ice tea. When he
is discharged the patients ability to access food will be a big factor of consideration by the care
team. Until admit Mr. T was getting nutrition exclusively orally but upon admit he was
immediately placed on TPN.
Mr. T is on many different medications including Ativan for his anxiety, hydrocodone for his
pain management, anti-nausea medications and Prilosec for heart burn. The definition of
polypharmacy is when a patient is on more than five medications. Polypharmacy is a common
problem in older adults with cancer because they often have other health problems in addition to
cancer, especially those who use tobacco and alcohol excessively. Although Mr. T isnt on
medications for other conditions like CVD or his COPD he is on medications to treat his side
effects of radiation like heartburn, nausea and anxiety. If not closely regulated then medications
can be either inhibited or exacerbated by interacting with one another or another drug may be
added to treat side effects from a different drug. Something to be aware of is drug-nutrient
interacts with foods that the patient might be consuming. In Mr. Ts case alcohol interacts
negatively with Ativan and hydrocodone causing dizziness and impaired judgment, Prilosec
inhibits absorption of folic acid and B12.
Mr. Ts biochemical data includes his albumin upon admit of 3.8 and as his oral intake decreased
dropped to 3.2 but currently, on TPN, it has gone up to 4. The normal range of albumin is 3.5-
5g/dL (Charney). The medical procedures that he has undergone since admit include a bedside
swallow evaluation, a PEG tube placement and weekly radiation. When he was admitted he was
six foot tall and 127 pounds currently on TPN he is at 131 pounds which is stable and a BMI of
17. Temporal wasting is visible as well as loss of fat mass on Mr. Ts arms. The swallow
evaluation revealed slight dysphagia and limited use of his tongue but ability to suck and breathe.
His affect is of a positive demeanor and he is very engaged and intent on listening to what is
being said about his condition. He has been a poor historian for his own medical history and
family medical history.
Diagnosis:
Malnutrition related to altered upper gastrointestinal function as evidenced by albumin of 3.8,
temporal wasting and BMI of 17 and oral squamous cell carcinoma.
Intervention:
Mr. T received radiation four times a week for seven weeks and remained in the hospital because
he had nowhere to go being homeless, and the local shelter could not support his needs. He was
started on total parenteral nutrition because of his low nutritional status. After two weeks his
weight stabilized and he had a PEG tube placed to start enteral feedings. The EN feeds were used
to get all of his nutrition while encouraging oral intake to maintain swallowing function. The EN
feeds continued for three weeks until he was switched to bolus feeds that he did himself and after
one week of bolus feeds he was switched back to TPN because of heartburn and nausea.
Once the PEG tube was placed Mr. T was on a nutrition prescription of 65ml/hr of jevity 1.5 to
give him 1800kcal per day plus 83 grams of protein and 50ml water flushes before and after
which, met his estimated needs of 1800cals and 85g of protein per day encouraging oral intake as
able.
Once TPN was restarted Mr. T was on a prescription of 85ml per hour plus a fat emulsion to give
him 2100kcal and 85 grams of protein which met his estimated needs of 1800kcal per day and 83
grams of protein encouraging oral intake as able.
These interventions were chosen to prevent further malnutrition due to altered oral function from
the patients oral squamous cell carcinoma. Both of the forms of nutrition aimed to increase total
protein status and stabilize or increase body weight.
Monitoring/Evaluation:
Mr. Ts lab values, average TPN received weekly and weight progress will continue to be
monitored. Overall, both nutrition interventions were effective for preventing further muscle
wasting, fat loss and lowered biochemical data. Body weight was maintained well when the Mr.
T was on the EN formula when it was constant, but once the bolus feeds were started he didnt
want to do all of the necessary boluses to get enough nutrition because he was too full and was
experiencing heart burn and discomfort. Once his body weight dropped about one kilogram the
physician was contacted to go back to constant feeds, the physician vetoed the suggestion and
Mr. T was placed on TPN the next day with a discontinue on all tube feeds. While on TPN Mr.
Ts albumin has increased to 4 and his weight is back to 131 and stable but oral intake is little to
none but encouraged.
Conclusions:
Although my time with Mr. T is not done, I will be following him up until discharge in a few
weeks, I have learned a lot about the nutrition care process and using it to communicate with
other healthcare professionals. I got to see firsthand how both EN and TPN can help a person
struggling with oral intake maintain and or gain weight as well as the effects that nutrition
support has on biochemical data and overall feeling of a patient. It was really interesting to see
how Mr. T improved in the way he looked and felt when he started getting enough nutrition
through his tube feeds and conversely, how downhill he went when he was not getting enough
nutrition with his bolus feeds. The changes in biochemical data was also really interesting to
observe once he was placed on TPN.
The other interesting learning point that I came to face was the communication between
physicians, nurses and dietitians within a health care setting. The oncologist that I was working
with is regarded as one of the best physicians in town and I believe it without a shadow of a
doubt but it was interesting that when we made a suggestion for a nutrition intervention, it was
completely ignored. The main reason that a PEG tube was placed was because a different
oncologist was filling in while the usual physician was on vacation and he read our notes and
acknowledged the suggestions even if he didnt always follow them. I was surprised that the
oncologist had his nurse call us and tell us no to the change in tube feed order back to constant
feeds without any reason as to why. Possibly the most surprising thing to me is that there hasnt
been hardly any acknowledgment with the social issue at hand that, Mr. T being homeless, will
not be able to continue TPN once radiation is complete and he needs to be discharged. The initial
thought behind the PEG tube was that once he is released he will still be able to give himself
boluses if the formula can be obtained, which is of question since he is unemployed. He is
currently on TPN and maintaining a stable weight but if the plan is to discharge him to a nursing
home or to a tent in the woods or my friends apartment. TPN will not be able to continue, due
to cost and lack of training, he will have to rely on oral intake or his PEG tube. Oral intake is
unlikely going to supply enough nutrition immediately after discharge because of his missing
teeth and pain while healing after radiation and he has not had enough practice with his tube
feeds or ability to get formula to be sure that he will get enough nutrition that way. It is likely
that after a month of TPN his stomach will shrink and his system will be overwhelmed by both
EN feeding and oral intake which he will likely have to rely on either at a nursing home or
home wherever that maybe. I look forward to looking into, and seeing how the social issues at
hand are addressed when it is time for discharge.
 References
Athanassios Argiris, Michalis V Karamouzis, David Raben, Robert L Ferris. Head and neck
cancer. The Lancet, Vol. 371:9625, 1723 May 2008, 1695-1709.
Unknown. Head and Neck Squamous Cell Carcinoma. Genetics Home Reference. Pub Jan. 2015.
https://ghr.nlm.nih.gov/condition/head-and-neck-squamous-cell-carcinoma#definition
Charney P., Ainsley M.M.. ADA Pocket Guide to Nutrition Assessment 2nd ed. Ch. 4 Laboratory
Assessments. 2009, 65-67.
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