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SILLIMAN UNIVERSITY
Building Competence, Character & Faith

NUTRITION CARE PLAN

Stage I Colonic Adenocarcinoma; Sigmoidectomy, Colostomy, Lymph
Node Resection Post-Surgery

In partial fulfillment for the requirements of the course

ND 90: Medical Nutrition Therapy I

For the degree

BACHELOR OF SCIENCE IN NUTRITION AND DIETETICS

Submitted by:
Kurt Jan Ronald J. Abrio
Christian Denzel T. Sagun
Vince B. Somido
Jenevieve R. Tolentino

Submitted to:
Prof. Circee Monte de Ramos, RND
Course Instructor

February 2018
TABLE OF CONTENTS
Introduction .......................................................................................... 4
Patient Profile......................................................................................... 5
I. Nutritional Assessment......................................................................... 6
A. Anthropometric............................................................... 6
i. Anthropometric Data.............................................. 6
ii. Medical, Social, and Health History......................... 7
B. Biochemical.................................................................... 9
C. Clinical........................................................................... 15
D. Dietary........................................................................... 17
i. Quantitative Assessment......................................... 18
ii. Qualitative Assessment.......................................... 22
II. Theoretical Considerations of the Disease............................................ 27
A. Disease Conditions......................................................... 27
B. Definitions...................................................................... 28
C. Etiology.......................................................................... 30
D. Incidence....................................................................... 32
E. Clinical Manifestations..................................................... 34
F. Pathophysiology Diagram................................................ 35
G. Pathophysiology Explanation........................................... 36
III. Nutrition Diagnosis............................................................................ 38
A. Intake Domain................................................................ 38
B. Clinical Domain............................................................... 40
C. Behavioral Domain.......................................................... 44
IV. Intervention...................................................................................... 45
A. Medical Intervention........................................................ 45
B. Nutrition Intervention...................................................... 54
i. Hospital Diet.......................................................... 66
ii. Maintenance Diet.................................................. 73
C. Implementation............................................................... 79
V. Nutrition Monitoring............................................................................. 80

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VI. Nutrition Evaluation............................................................................ 82
Conclusion.............................................................................................. 84
Reflection............................................................................................... 85
References.............................................................................................. 89

INTRODUCTION

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 Ageing is a continuous process occurring throughout adult life. The
health and nutrition of elderly adults are vital since the risks of both mortality
and disability increase in a roughly exponential way throughout adult life due to
progressive loss of adaptability (Webb, G., & Copeman, J., 1996).
The gastrointestinal system plays an important role in bodily functions
since it is responsible for digestion of food, absorption of nutrients, and
elimination of waste from the body. Disease factors related to the
gastrointestinal system require proper nutrition and medical therapy to relieve
symptoms and complications.
Colorectal cancer is the third commonest cancer and the third
leading cause of cancer death among men and women. It has been proposed
that dietary factors are responsible for 70-90% of colorectal cancer and diet
optimization may prevent most cases (Pericleous, M., Mandair, D., & Caplin, M.,
2013). Adenocarcinoma is a type of cancer that starts in the cells that form
glands making mucus to lubricate the inside of the colon and rectum. This is the
most common type of colon and rectum cancer (American Cancer Society, 2017).
Adenocarcinomas that arise in the small intestine usually occur in the upper small
bowel. The growth of this type of tumor is more common among patients with
celiac disease, Crohn's disease, and dermatitis herpetiformis. Histological findings
show that adenocarcinomas are mucus-secreting which present at ulcerating
obstructing neoplasms. These metastasize to regional lymph nodes and the liver
(Souhami & Moxham, 1990). Intestinal obstruction contributes to weight loss in
the patient (The Merck Manual of Medical Information, 1997). Patients with
adenocarcinoma in the small intestines usually present with abdominal pain, and
intussusception may occur causing acute obstruction. Chronic blood loss is
frequent and there may be melena. The diagnosis can sometimes be made by
small bowel enema and occasionally endoscopically (if in the duodenum) or by
colonoscopy (if in the terminal ileum) (Souhami & Moxham, 1990).
PATIENT PROFILE

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 The patient is Erlinda Canizares, a 68-year old female, residing in Habitat,
Cadawinonan, Dumaguete City, Negros Oriental. The patient is married and
works as a book keeper but forced to retire last 2009 – 2010 due to stroke.
During her first stroke her usual intake was to minimize meat and proceeded to
NGT during her second stroke. She reports not doing any drugs, tobacco
smoking nor alcohol use but is a coffee drinker.
She suffered a mild stroke last 2009 and was diagnosed to have Diabetes
Mellitus. And after 2 months, brain symptoms showed. Her second stroke was
Jan, 2018 and it led to memory loss. The patient was admitted at the Silliman
University Medical Center Foundation, Inc. on August 2, 2018, Room no. 325.

I. NUTRITIONAL ASSESSMENT

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A. Anthropometric Assessment

i. Anthropometric Data
The table below contains the data of patient’s anthropometric assessment, which
will be used to correlate with her nutrition status. It shows the values and
interpretation of the patient’s current status.

INDICATOR RESULT REFERENCE DESCRIPTION INTERPRETATION

RANGE
Body Mass 24.49 20.0 - 24.9 Normal The patient's BMI is
Index (BMI) (Normal) Normal according to
the FAO/WHO.
Body Weight 55 kg (usual 44 kg (DBW) Usual weight is The patient's usual
(DBW) weight) above DBW weight is 95.74% of
the desirable body
weight based on
the Tannhauser's
method.
Height 4'11" 4'9" Above Normal The patient's height
is below normal for
her weight and age
according to the
Mean Height and
Weight For Filipinos
20 and above.

ii. Medical, Social, and Health History

Chief Complaint Diabetes Mellitus, Hypertension and Stroke

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Past Illness Mild stroke (2009)
Surgeries Caesarian and knee surgery (2000)
Immunizations Unknown
Family Health History Hypertension on father's side and Diabetes Mellitus on
the mother’s side.
Alcohol Use None
Drug Use None
Cigarette Smoking None
Sexual Practice None
Stressor None
Maintenance Glucerna for her Diabetes Mellitus (Just in case of
emergency)
Food Allergies None
Travel History None
Treatment, if any Diabetes Mellitus and
Medicines prescribed are as follows:
1. Glucerna 400g
2. Hemostan 500mg ampule (PNF)
3. Clindal 300mg/2ml (PNF)
4. Zeptrigen 1g vial (PNF)
5. Plasil 10mg ampule (PNF)
6. Biogesic 500mg tablet (PNF)
7. Lipitor 20mg (PNF)

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B. Biochemical Assessment
The series of tables below show the patient's complete blood count (CBC), clinical chemistry, and blood gases test results,
which will be used to correlate with her nutritional status. It shows the results, normal ranges, descriptions, and
interpretations.

Complete Blood Count, August 1, 2018, 12:45

PARAMETER RESULT REFERENCE DESCRIPTION INTERPRETATION

RANGE
Hemoglobin 13.20 % 12-14 Normal Hemoglobin level in the blood is within
normal range.
Hematocrit 37.20 % 37-44 Normal Hematocrit level in the blood is within normal
range.
White Blood Cell 17520/cumm 4500-11000 Above Normal The white blood cell level in the blood is
above normal.
Segmenters 93 % 55-70 Above Normal This indicates neutrophilia, which can be
caused by acute bacterial infections,
inflammation, trauma, heart attack, burns,
stress, rigorous exercise, certain leukemias,
and/or Cushing syndrome ("Complete Blood
Count (CBC)," 2015).
Lymphocyte 3% 20-35 Below Normal This indicates lymphocytopenia, which can be
seen in autoimmune diseases, infections,
bone marrow damage, and the use of
corticosteroids ("Complete Blood Count
(CBC)," 2015).
Eosinophil 0% 1-4 Below Normal The eosinophil level in the blood is below
normal range.
Monocyte 4% 1-6 Normal The monocyte level in the blood is within
normal range.
Basophil 0% 0.00-1.00 Normal The basophil level in the blood is within
normal range.
Platelet Count 262 T/cumm 150-400 Normal The platelet count in the blood is within
normal range.
Red Blood Cell 4.5 M/cumm 4.2-5.4 Normal Red blood cell level in the blood is within
normal range
Mean Corpuscular 83 fL 80-96 Normal The mean corpuscular volume in the blood is
Vol within normal range.
Mean Corpuscular 29.5 pg 27-31 Normal The mean corpuscular Hgb level in the blood
Hgb is within normal range.
Mean Corpuscular 35.5 % 33-36 Normal The mean corpuscular conc. level in the
Conc. blood is within normal range.
 Clinical Chemistry, August 1, 2018, 12:45

PARAMETER RESULT REFERENCE DESCRIPTION INTERPRETATION

RANGE
Sodium 130.60 mEq/L 135-145 Normal The sodium levels in the blood fall within
normal range.
Potassium 4.00 mEq/L 3.6-5.0 Normal The potassium levels in the blood fall within
normal range.
Albumin Serum 2.10 g/dL 3.5-5.0 Below Normal A low serum albumin count can be seen in
inflammation, shock, malnutrition, infection,
burns, surgery, chronic illness, cancer,
diabetes, hypothyroidism, carcinoid syndrome,
plasma volume expansion due to congestive
heart failure, and/or seen in Crohn's disease
or celiac disease ("Albumin," 2016)
C. Clinical Assessment

General Survey

INDICATOR RESULT REFERENCE RANGE DESCRIPTION

Blood Pressure 100/70 120/80 - 140/90 Below Normal

mmHg
Temperature 37.3 °C 36.5 °C - 37.2 °C Slightly Above
Normal
Resting Pulse Rate 72 bpm 70 - 100 bpm Normal

Respiration Rate 20 bpm 12 - 20 bpm Normal

INDICATOR DESCRIPTION
Skin Appearance of lumps. no signs of rashes, sores,
jaundice, changes in size of moles, changes in hair or
nails.
Head, scalp, and face No signs of headache, colds, hoarseness, dizziness, ear
aches, tinnitus, nasal stuffiness, swollen glands, light
headedness, blurry of vision, eye pain, sore throat,
change in hearing and nasal discharges/epistaxis.
Neck No neck pain/stiffness
Chest and lungs No cough, hemophysis, dyspnea, pleuritic chest pain
Cardiovascular No chest discomfort, chest tightness, palpitation,
orthopenia, PND
Abdomen No signs of dysphagia, diarrhea, odynophagia,
constipation, nausea, hematemesis, heart burn,
hematochezia, metema, abdominal pain, changes in
BM. Experiencing vomiting.
Genitourinary Grossly normal, no discharge, (-) RPS
Musculoskeletal no signs of arthralgia, myalgia, stiffness and limitation
of motion.
Neurological There are positive changes in orientation, attention,
 speech, memory and experiencing seizures.

Cranial Nerves:
I. Identifies odor in each nostril
II. PERLLA
III, IV, VI. Follows penlight in six cardinal gazes
V. Identifies sensation in forehead, clenches jaw
VII. Devates eyebrows
VIII. Hears on both ears
IX, X. Positive gag reflex
XI. Shrugs shoulders
XII. Tongue midline

D. Dietary Assessment
The following tools below show the dietary intake of the patient and it will be
analyzed both qualitatively and quantitatively. This will be the basis for the
nutritional management of the patient.

Usual Food Intake

TIME FOOD ITEM MEASURE LOCATION

Adobong kangkong 1 cup cooked
Ripe papaya 3/4 cup
Rice, cooked 1 cup
Breakfast Oil 1 tsp
Sara-sara 1/4 cup
Milk for sara-sara 1/4 cup
Sugar, brown 1 tsp
Kalabasa (ginataan) 1 cup cooked
Rice, cooked 2 cups
Coconut, grated 4 tbsp
Chicken, whole 3 matchbox
Lunch House
slices
Oil 1 tsp
Banana, lakatan 1 piece (9x3
cm)
Sara-sara 1/4 cup
Milk for sara-sara 1/4 cup
PM Snack
Sweet potato 1 pc 11 cm
long
Law-uy (malunggay) 1 cup cooked
Dinner
Rice, cooked 1 cup
i. Quantitative Assessment

# of exchanges CHO (g) CHON (g) Fat (g) Energy (kcal)

I.A. Vegetable A 4 6 2 - 32
I.B. Vegetable B 2 3 1 - 16
II. Fruit 2 20 - - 80
III. Milk 2 24 16 20 340
IV. Rice 11 253 22 - 1,100
V. Meat
Low fat 3 - 24 3 123
Medium fat - - - - -
High fat - - - - -
VI. Fat 2 - - 10 90
VII. Sugar 2 - - - 40
TOTAL 316 65 33 1,821

Food Composition Table

Diet Rating
LEGEND: Percent RENI
Good 90% - above
Fair 70% - 89%
Poor 50% - 69%
Very Poor 49% - lower

Interpretation for diet rating

TOTAL
NUTRIENT RENI VALUE PERCENTAGE INTERPRETATION
INTAKE
Energy 2,144 1,610 133% Good
Protein 56.4 62 91% Good
Calcium 978 800 122% Good
Phosphorus 1,013 700 145% Good
Iron 14 10 140% Good
Vitamin A 793 600 132% Good
Thiamin 0.66 1.1 60% Poor
Riboflavin 1.57 1.1 143% Good
Niacin 23.9 14 171% Good
Vitamin C 150 60 250% Good

Based on the diet rating from the patient's usual food intake, most
of her nutrient intake is rated "good" from 91% up to 250% of RENI, except for
thiamin, which is rated "poor" at only 60%.
 FOOD GROUP 1x /day 2x /day 3-4x 1x /week 2x /week 3-4x 5-6x SELDOM

FOOD GROUP 1x /day 2x /day /day

3-4x 1x /week 2x /week /week
3-4x /week
5-6x SELDOM
Fried
/day /week /week
Vegetables
Steamed 
Fruits 
Pan Grilled
Milk
Grilled
Sugar 
Boiled
Rice 
Stewed
Pasta 
Roasted
Bread 
Raw
Cereals/oats
Others
Low fat meat

Medium fat meat

High fat meat

Fat
ii. Qualitative Assessment Cooking Method 
Food Frequency Table
Interpretation for food frequency table

Based on the patient's food frequency table, she eats fruits once a
day, and vegetables twice a day. She drinks milk once a day. Her sugar intake is
about once a day. Rice is eaten about three times a day, pasta is eaten three to
four times a week, and bread is eaten once a day. High fat and medium fat meat
and fat are eaten seldom while low fat meat such as chicken is eaten about once
a day. Fat such as oils is used about twice a day.

Interpretation for cooking method

 Daily Nutritional Guide for Filipino Older Adults (60-69 years old)

The group used the food pyramid for 60-69 years old as the basis for the food
pyramid comparison and diet creation.
 Food Pyramid Patient Comparison

FOOD GROUP REFERENCE INTAKE INTERPRETATION

RANGE
Water/Beverages 6 - 8 glasses 6 glasses Within Range
Rice, Rice products,
Corn Root, Crops, 4 1/2 - 6 servings 5 1/2 servings Within Range
Bread, Noodles
Fruits 2 servings 2 servings Within Range
Vegetables 3 servings 3 servings Within Range
Milk and Milk
2/3 - 3/4 glass 1/2 glass Below Range
products
Eggs 1 piece 0 pieces Below Range
Fish, Shellfish, Meat
and Poultry, Dried 3 servings 3 servings Within Range
Beans and Nuts
Sugar/Sweats 4 - 6 tsps 2 tsp Below Range
Fats and Oils 2 - 5 tsps 2 tsp Within Range

Interpretation

Water/beverages, rice and rice substitutes, fruits, vegetables, and

meat products falls within range. Milk, eggs, sugar, and fats fall below range.
II. THEORETICAL CONSIDERATIONS OF THE DISEASE

A. Disease Conditions

A month prior to admission, the patient complained about

abdominal distention with discomfort, coupled with weight loss and nausea. Two
weeks prior to admission, the patient complained about dyspnea with
progressive abdominal distention, coupled with nausea, vomiting, and body
malaise. Post-operative diagnosis shows complete bowel obstruction secondary
to sigmoid mass. Pathological diagnosis states there is a presence of a well-
differentiated, colonic adenocarcinoma. The tumor was classified as pT2N0M0,
meaning that the tumor has grown into the muscularis propria, there is no
spread to regional lymph nodes, and the disease has not spread to a distant part
of the body ("Colorectal Cancer: Stages," 2017). A sigmoid mass resection and
colostomy were undergone. A resection of fifteen pericolic lymph nodes was
undergone and showed negative for tumor involvement. In addition to the
severe weight loss, nausea, and vomiting, clinical chemistry and complete blood
count results show the patient is experiencing anemia, hypokalemia,
hypoalbuminemia, hypocalcemia, neutrophilia, and lymphocytopenia. Blood gas
test results show that the patient may be experiencing a side effect called
respiratory alkalosis, which is caused by hyperventilation from anxiety or pain
(Tidy, 2015). Symptoms of cancer cachexia are evident due to severe weight
loss, muscle wasting, and weakness.
B. Definitions

Adenocarcinoma is a type of cancer that starts in the cells that

form glands making mucus to lubricate the inside of the colon and rectum. This
is the most common type of colon and rectum cancer (American Cancer Society,
2017).
Cachexia is the most common metabolic disturbance associated
with cancer and it is a state of profound weight loss, muscle wasting, and
weakness (The Merck Manual of Medical Information, 1997).
Anemia is a condition that occurs when the hemoglobin
concentration in the blood falls below the normal range, together with age and
sex of the individual factored in. Iron-deficiency anemia is the commonest form
of this condition and is particularly prevalent in underprivileged communities
(The Merck Manual of Medical Information, 1997). Although anemia among the
elderly may be nutritional or non-nutritional in origin, various factors such as
drug use, malabsorption, or lifestyle must be taken in account (Roe, 1992).
Lymphocytopenia is the condition of abnormally low level of
lymphocytes in the blood, while neutrophilia is the condition with a high level
of neutrophils circulating in the blood ("Complete Blood Count (CBC)," 2015).
Hypokalemia is defined as a significant reduction of plasma
potassium in the blood and it usually indicates depletion of total body potassium
but can occasionally be die to temporary shifts of potassium ions from the extra
to intracellular spaces. Plasma potassium concentration below 3.8 mill
equivalents (mEq) per liter of blood indicates hypokalemia (The Merck Manual of
Medical Information, 1997).
Hypoalbuminemia is associated as a proportionate fall in plasma
total calcium, although not in ionized form. The ionized calcium concentration is
affected by the blood pH, since the avidity of albumin for calcium falls at acid pH
and rises with alkalosis (Souhami & Moxham, 1990).
 Hypocalcemia is defined as low calcium levels in the blood with a
blood calcium concentration below 8.8 milligrams per deciliter of blood (The
Merck Manual of Medical Information, 1997).
Respiratory alkalosis is respiratory ventilation over and above
the required to remove CO2 resulting in reducing PaCO2 (Hayes & Mackay, 1992).
C. Etiology

Adenocarcinomas that arise in the small intestine usually occur in

the upper small bowel. The growth of this certain tumor is more common among
patients with celiac disease, Crohn's disease, and dermatitis herpetiformis.
Histological findings show that adenocarcinomas are mucus-secreting which
present at ulcerating obstructing neoplasms. These metastasize to regional
lymph nodes and the liver (Souhami & Moxham, 1990). Intestinal obstruction
contributes to weight loss in the patient (The Merck Manual of Medical
Information, 1997).
Anemias in patients who have undergone partial gastrectomy
(nearly half of them) develop an iron deficiency if not given iron supplements,
due primarily to rapid gastrojejunal transit. Achlorydia may also cause iron
deficiency, as hydrochloric acid is important for the absorption of iron contained
in foodstuffs. The cause of iron deficiency must always be established and
particular attention paid to possible gastrointestinal bleeding. Malignancies of the
gastrointestinal tract may present with iron deficiency anemia in the absence of
any other symptoms (Souhami & Moxham, 1990).
In cachexia, anorexia is believed to be the major cause of it
although many factors contribute to the condition. Before metastasis of upper
gastrointestinal tract tumors, loss of appetite usually occurs. This leads to a lack
of nutrient intake, muscle wasting, weight loss, and weakness (Souhami &
Moxham, 1990).
Lymphocytopenia occurs when the body doesn't make enough
lymphocytes, destruction of lymphocytes, or when lymphocytes get stuck in the
spleen or lymph nodes. Acquired causes include infectious diseases, autoimmune
diseases, steroid therapy, blood cancer, radiation and chemotherapy. On the
other hand, inherited causes include rare cases like Wiskott-Aldrich syndrome
and DiGeorge anomaly (National Heart, Lunch, and Blood Institute, n.d.).
Neutrophilia can arise from infections, stressful conditions, chronic
inflammation, medication use (e.g. corticosteroids), infection, bone marrow
stimulation, pregnancy, obesity, race, and age (Riley & Ruper, 2015).
Hypokalemia may result from excessive renal loss (e.g. diuretic
therapy or magnesium deficiency), GI loss (e.g. diarrhea, vomiting), metabolic
imbalance (e.g. alkalosis, insulin therapy, or in periodic paralysis), and endocrine
causes (e.g. hyperaldosteronism, Cushing's syndrome) (Hayes & Mackay, 1992).
Albumin is the major calcium-binding protein in plasma; therefore,
hypoalbuminemia is associated with a proportionate fall in plasma total
calcium. Respiratory alkalosis due to over breathing can lead to depression of
ionic calcium and tetany (Souhami & Moxham, 1990).
Hypocalcemia is caused with low levels of PTH
hypoparathyroidism, post-surgical, congentinal, idiopathic (autoimmune), with
normal or high levels of PTH rickets/otsteomalacia, sunlight/dietary deficiency,
malabsorption, increased D metabolism, tumor-induced, chronic renal failure and
pseudohypoparathyroidism (The Merck Manual of Medical Information, 1997).
Respiratory alkalosis may be caused by hysterical overbreathing,
assisted ventilation (overventilation), lobar pneumonia, pulmonary embolism,
meningitis, encephalitis, poisoning with salicylate, and hepatic failure (Hayes &
Mackay, 1992).
D. Incidence

Colorectal cancer is the third commonest cancer and the third

leading cause of cancer death among men and women. It has been proposed
that dietary factors are responsible for 70-90% of colorectal cancer and diet
optimization may prevent most cases (Pericleous, M., Mandair, D., & Caplin, M.,
2013).
In the Philippines, 75% of all cancers occur after age 50 years, and
only about 3% occur at age 14 years and below. If the current low cancer
prevention consciousness persists, it is estimated that for every 1800 Filipinos,
one will develop cancer annually. At present, most Filipino cancer patients seek
medical advice only when symptomatic or at advanced stages: for every two new
cancer cases diagnosed annually, one will die within the year (Ngelangel, C.A., &
Wang, E.H., 2002).
The survival experience, regardless of treatment, of patients with
top cancer sites diagnosed in 1987 and included in the DOH–RCR was evaluated
as the first population-based survival data for Filipinos. Lung cancer had the
lowest survival and breast cancer had the highest. Five-year survival in excess of
40% was observed for only three cancer sites: oral cavity, colon and breast. For
all other sites, survival was less than 30%. Owing to the small number of cases
in each category, no distinct impact of age on relative survival could be
perceived for most cancer sites. However, both observed and relative survival
rates were low for breast cancer patients less than 35 years old (Ngelangel, C.A.,
& Wang, E.H., 2002).
The 1987 cancer survival rates among Filipino patients imply that
there is much to be done for cancer education and the implementation of all
aspects of cancer prevention. In comparison, the 1990 5-year relative survival
rates, all races, from the USA National Cancer Institute Surveillance Epidemiology
End-result program reveals higher rates except for stomach (males) and liver
cancers (Ngelangel, C.A., & Wang, E.H., 2002).
 The prevalence of anemia was determined among 36,364 randomly
selected Filipinos, 6 months of age and over covered by the 1998 Fifth National
Nutrition Survey in all the provinces of the 16 regions of the country, except
Basilan and Lanao del Sur. Anemia was was assessed using hemoglobin as the
parameter. Results showed that the over-all prevalence of anemia increased
slightly to 30.9 % from 8.9% obtained in the 1993 survey. Infants 6 mo - (1 y
had the highest prevalence (56.6%), followed by pregnant women (50.3%),
male elderly (49.1%) and lactating women (45.7%). While the 1-5 y old children
as a group had relatively low prevalence of 29.6%, a disaggregation of this
population group into single age grouping revealed alarmingly high rates of
53.2& and 36.9% for 1 and 2 y old children, respectively. Based on the criteria
set by FAO/WHO, the magnitude of the anemia problem in children, 6 months -
1 year old, and also in pregnant and lactating women, was considered high
(Cheong, R.L, et al, 2013).
E. Clinical Manifestations

Patients with adenocarcinoma in the small intestines usually

present with abdominal pain, and intussusception may occur causing acute
obstruction. Chronic blood loss is frequent and there may be melena. The
diagnosis can sometimes be made by small bowel enema and occasionally
endoscopically (if in the duodenum) or by colonoscopy (if in the terminal ileum)
(Souhami & Moxham, 1990).
Patients with cachexia usually show symptoms of anorexia and
loss of appetite. Cachexia affects nearly half of cancer patients, causing the
clinical manifestations of anorexia, muscle wasting, weight loss, early satiety,
fatigue, and impaired immune response (Esper & Harb, 2005).
In patients with lymphocytopenia, a low lymphocyte count alone
may not cause any signs or symptoms. The condition usually is found when a
person is tested for other diseases or conditions, such as AIDS (National Heart,
Lunch, and Blood Institute, n.d.). Neutrophila is seen as a presence of left
shift, abnormalities on the blood film, and a splenomegaly ("Neutrophilia," n.d.)
Hypokalemia is manifested in terms of muscular weakness,
polyuria, ECG changes with U-waves and flattened T-waves, and ileus (Hayes &
Mackay, 1992). Hypoalbuminemia may be symptomatic, or manifested in
terms of muscle weakness, fatigue, cramps, and/or poor appetite
("Hypoalbuminemia (Low Albumin)," n.d.). Hypocalcemia is often
asymptomatic, discovered on biochemical screening, weakness, constipation,
confusion, anorexia, renal colic, polyuria, polydipsia, and proximal myopathy
(Hayes & Mackay, 1992).
Respiratory alkalosis is seen as rapid deep respiration, tetany,
paraesthesia particularly perioral and peripheral, light-headedness and collapse
(Hayes & Mackay, 1992).
F. Pathophysiology
G. Pathophysiology Explanation

The predisposing factors for colonic and rectal cancer that applies to the
patient are: age, inflammatory bowel disease, and low calcium diet (Ruiz, A. J.,
Claudio, V. S., & De Castro, E. E., 2011). The prevalence of cancer is higher
among the elderly and it increases with age, with the greatest frequency during
the fifth, sixth, and seventh decades of life. Majority of persons with carcinoma
of the colon are in the older age group because this cancer is usually very slow
growing and remains localized for a long time (Bullock, 1996). As evidenced by
the patient's dietary assessment, her food pyramid comparison shows a lack of
milk and milk product intake. These risk factors may all contribute to the
patient's development of a colonic adenocarcinoma.
According to the patient interview and charts, she reported nausea,
vomiting, and constipation as symptoms during pre-admission. Post-operative
diagnosis showed a tumor growth in the sigmoid colon, which prompted a
colostomy and sigmoidectomy. As seen on the operative record of the patient,
fifteen pericolic lymph nodes were removed during the lymph node resection that
was also done during the operation, but the results showed negative of tumor
involvement. Lymphocytopenia occurs when the body doesn't make enough
lymphocytes, destruction of lymphocytes, or when lymphocytes get stuck in the
spleen or lymph nodes (National Heart, Lunch, and Blood Institute, n.d.).
Because of this, lymphocytopenia was observed in the complete blood count
(CBC) test in the biochemical assessment. Tumors in the body tend to bleed,
which causes a resultant loss of iron and these symptoms are usually
characteristic with tumors in the colon (Colorectal Cancer Canada, n.d.).
Therefore, the anemia evident in the patient's complete blood count test (CBC)
might be indicative of iron-deficiency anemia.
The metabolic response to post surgery is accompanied by stress
response, which causes an increase in demand for calories and protein, together
with a hormonal and inflammatory response that causes anorexia (Ruiz, et al,
2011). Cachexia is a common metabolic disturbance associated with cancer, with
anorexia as the major cause. The tumor may also promote weight loss by direct
metabolic effects such as excess lactate production, malabsorption, and/or
intestinal obstruction (Souhami & Moxham, 1990).
Stress can decrease the serum albumin levels in the blood, and
hypoalbuminemia has a negative effect on wound healing and makes nutritional
repletion difficult (Bullock, 1996). Albumin is the major calcium-binding protein
in plasma; therefore, hypoalbuminemia is associated with a proportionate fall in
plasma total calcium. Respiratory alkalosis due to over breathing can lead to
depression of ionic calcium and tetany (Souhami & Moxham, 1990).
Hypocalcemia may also be manifested post-surgery or tumor-induced (The Merck
Manual of Medical Information, 1997).
Because of the tumor formation on the sigmoid colon, the patient
was diagnosed with complete small bowel obstruction secondary to sigmoid
mass. Dyspnea occurred according to the patient's complaint pre-admission and
this could be caused by the intestinal obstruction. Because of the dyspnea, the
patient had to undergo respiratory support in the form of a nebulizer and she
was prescribed with Ventolin, which is a corticosteroid. The patient's complete
blood count (CBC) test results showed manifestations of neutrophilia. This can
arise from infections, stressful conditions, chronic inflammation, medication use
(e.g. corticosteroids), and age (Riley & Ruper, 2015).
Dyspnea is a condition where there is shortness of breath (Merck).
Respiratory alkalosis may result in excessive loss of carbon dioxide to alveolar
hyperventilation (Bullock, 1996). Hypokalemia is then caused by GI loss (e.g.
diarrhea, vomiting) and metabolic imbalance like alkalosis (Hayes & Mackay,
1992). Respiratory alkalosis causes a decrease in ionized calcium, which may
then cause hypocalcemia (Souhami & Moxham, 1990).
III. NUTRITION DIAGNOSIS
The list below shows the problem, etiology, signs and symptoms (PESS) with the
reference to support the diagnosis of the patient. It is categorized according to
the nature of the etiology: intake domain, clinical domain, and behavioral intake.

i. Intake Domain

Problem: Lack of thiamin (vitamin B1) intake

Etiology: Faulty eating habits
Signs/Symptoms: As evidenced by the diet rating based on the patient's usual
food intake in the dietary assessment
Vitamin B1, or thiamin, is an integral part of the coenzyme factor
thiamin pyrophosphate or TPP, which is needed for the metabolism of
carbohydrates. In the form of thiamin diphosphate, it hastens the conversion of
glucose to fat by transketolation reactions. This vitamin is important because it
has a role maintaining good appetite, muscle tone of the GIT, and functioning of
the nerves. Deficiency of thiamin is shown in the form of weakness, loss of
appetite, gastrointestinal disturbances such as constipation, indigestion, gastric
atony, and poor reflexes with numbness of extremities. Later stages of thiamin
deficiency cause beriberi, which affects both the cardiovascular and nervous
systems (Ruiz & Claudio, 2010).

Problem: Alcohol intake

Etiology: Lifestyle factors
Signs/Symptoms: As evidenced by patient interview and patient profile
Frequent alcohol intake causes malnutrition in a way that eating
becomes inadequate and it is not efficiently utilized as a source of energy or as a
physiological food source. The liver is the most affected organ, which becomes
overworked in order to metabolize and detoxify alcohol (Ruiz & Claudio, 2010).
Problem: Lack of milk and milk products and egg intake
Etiology: Poverty, availability, and proximity of household to market
Signs/Symptoms: As evidenced by the patient's usual food intake and food
pyramid comparison
Milk and eggs are good sources of protein, carbohydrates, and fat,
and helps reach total energy requirement per day. Milk contains vitamins and
minerals important in the normal function of the body, while eggs are a cheap
source of high biological value (HPV) protein (Ruiz & Claudio, 2010).
ii. Clinical Domain

Problem: Stage I Colonic Adenocarcinoma

Etiology: The tumors usually occur in the upper small bowel and are more
common in patients with celiac disease, Crohn's diseases, and dermatitis
herpetiformis. Histologically, there are mucus-secreting adenocarcinomas, which
present as ulcerating obstructing neoplasms. They metastasize to regional lymph
nodes and the liver (Souhami & Moxham, 1990).
Signs/Symptoms: As evidenced by the patient's biochemical and clinical
assessment
Patients with abdominal pain, and intussusception may occur
causing acute obstruction. Chronic blood loss is frequent and there may be
melena. The diagnosis can sometimes be made by small bowel enema and,
occasionally, endoscopically (if in the duodenum) or by colonoscopy (if in the
terminal ileum) (Souhami & Moxham, 1990).

Problem: Post-operative stress response due to sigmoidectomy, colostomy, and

lymph node resection
Etiology: The body's metabolic response to surgery is accompanied by stress. It
is designed to meet the metabolic demands from surgery and it involves the
secretion of epinephrine, norepinephrine, and corticosteroids resulting in the
breakdown of glycogen, fat stores, and body proteins.
Signs/Symptoms: As evidenced by the patient's anthropometric, biochemical,
and clinical assessment
The catabolic responses to surgery vary depending on the extent of
tissue damaged. There is a negative nitrogen balance due to the increased
excretion of urea and nitrogenous products in the urine, and loss of protein
through the injured tissues in individuals with large open wounds. There is also a
hormonal and inflammatory response that contributes to the catabolic effects,
either directly or indirectly. There is also a translocation of amino acids to
visceral organs and the wound that allows the amino acids to serve as host
defenses and support vital organ function and wound repair (Ruiz, et al, 2011).

Problem: Cancer cachexia

Etiology: It is a common metabolic disturbance associated with cancer, with
anorexia as the major cause. The tumor may also promote weight loss by direct
metabolic effects such as excess lactate production, malabsorption, and/or
intestinal obstruction (Souhami & Moxham, 1990).
Signs/Symptoms: As evidenced by the patient's anthropometric and clinical
assessment through severe weight loss and muscle wasting
Cancer cachexia is the state of profound weight loss, muscle
wasting, and weakness (Souhami & Moxham, 1990). It is a multifactorial
syndrome that cannot be fully reversed by conventional nutritional support and
leads to progressive functional impairment (Ruiz, et al, 2011).

Problem: Iron-deficiency anemia (in colon cancer)

Etiology: Tumors in the body tend to bleed, which causes a resultant loss of
iron and these symptoms are usually characteristic with tumors in the colon
(Colorectal Cancer Canada, n.d.)
Signs/Symptoms: As evidenced by the patient's complete blood count (CBC)
results in the biochemical assessment

Problem: Hypokalemia
Etiology: This may result from excessive renal loss (e.g. diuretic therapy or
magnesium deficiency), GI loss (e.g. diarrhea, vomiting), metabolic imbalance
(e.g. alkalosis, insulin therapy, or in periodic paralysis), and endocrine causes
(e.g. hyperaldosteronism, Cushing's syndrome) (Hayes & Mackay, 1992).
Signs/Symptoms: As evidenced by the patient's clinical chemistry test results
in the biochemical assessment
 Hypokalemia, or potassium deficiency, may be seen as generalized
weakness, polyuria, ECG changes with U-waves and flattened T-waves, and ileus
(Hayes & Mackay, 1992). Potassium maintains fluid and electrolyte balance, and
it is important for carbohydrate and protein metabolism (Ruiz & Claudio, 2010).

Problem: Hypoalbuminemia
Etiology: Albumin is the major calcium-binding protein in plasma; therefore,
hypoalbuminemia is associated with a proportionate fall in plasma total calcium,
though not in ionized calcium. Respiratory alkalosis due to over breathing can
lead to depression of ionic calcium and tetany (Souhami & Moxham, 1990).
Signs/Symptoms: As evidenced by the patient's clinical chemistry test results
in the biochemical assessment
Albumin is normally present in the blood and constitutes 50—60%
of the plasma proteins and 80—85% of the oncotic pressure (Prescribers' Digital
Reference, n.d.).

Problem: Hypocalcemia
Etiology: It is caused with low levels of PTH hypoparathyroidism, post-surgical,
congentinal, idiopathic (autoimmune), with normal or high levels of PTH
rickets/otsteomalacia, sunlight/dietary deficiency, malabsorption, increased D
metabolism, tumor-induced, chronic renal failure and pseudohypoparathyroidism
(The Merck Manual of Medical Information, 1997).
Signs/Symptoms: As evidenced by the patient's clinical chemistry test results
in the biochemical assessment
Calcium functions in bone and teeth formation, muscular
contraction, blood coagulation, nerve transmission, enzyme activation and
catalyst for biological reactions, and helps lower hypertension. Vitamin D
enhances the optimum absorption of calcium by increasing the permeability of
the intestinal membrane to calcium and by activating the active transport system
(Ruiz & Claudio, 2010).
Problem: Lymphocytopenia
Etiology: It occurs when the body doesn't make enough lymphocytes,
destruction of lymphocytes, or when lymphocytes get stuck in the spleen or
lymph nodes. Acquired causes include infectious diseases, autoimmune diseases,
steroid therapy, blood cancer, radiation and chemotherapy. On the other hand,
inherited causes include rare cases like Wiskott-Aldrich syndrome and DiGeorge
anomaly (National Heart, Lunch, and Blood Institute, n.d.).
Signs/Symptoms: As evidenced by the patient's complete blood count (CBC)
results in the biochemical assessment

Problem: Neutrophilia
Etiology: It can arise from infections, stressful conditions, chronic inflammation,
medication use (e.g. corticosteroids), infection, bone marrow stimulation,
pregnancy, obesity, race, and age (Riley & Ruper, 2015).
Signs/Symptoms: As evidenced by the patient's complete blood count (CBC)
results in the biochemical assessment

Problem: Respiratory alkalosis

Etiology: Metabolic respiratory alkalosis occurs due to a loss of acid from the
stomach or renal tract. Volume contraction due to diuretic administration results
in alkalosis, as does hypokalemia by increasing HCO 3 reabsorption. Excessive
mineralocorticoids, either endogenous or exogenous result in metabolic alkalosis.
Signs/Symptoms: As evidenced by the patient's blood gases test results in the
biochemical assessment
iii. Behavioral/Environmental Domain
Problem: Takes advice and intervention from local healer instead of a trained
health worker or medical doctor
Etiology: Poverty, lack of knowledge, proximity of household to health center or
hospital
Signs/Symptoms: As evidenced by patient profile and patient interview
Taking advice and following the recommended intervention from a
non-medical professional who have not undergone medical training and studies
might lead to contradictory knowledge or poor and flawed medical intervention
to the person consulting them in the first place. The recommendations made
might be detrimental to their health.

Problem: Lack of knowledge of proper health and nutrition

Etiology: Poverty, lack of proper education, and/or ignorance
Signs/Symptoms: As evidenced by food and lifestyle choices in the patient
profile and dietary assessment
The lack of knowledge of food and nutrition might lead to
detrimental effects to one's health by following recommendations or having
beliefs that do not correlate with scientific and medical principles.
IV. INTERVENTION

A. Medical Intervention

MEDICINE ACTION FOOD AND DRUG INTERACTION

B. Nutrition Intervention

PROBLEM GOAL PRINCIPLE RATIONALE REFERENCE

Stage I Colonic  To treat and alleviate  Surgical resection is  Surgical resection is the only Souhami, R. L., &
Adenocarcinoma any symptoms and performed curative treatment for Moxham, J.
complications  Avoid cooking meat at high adenocarcinoma (1990). Textbook
 To prevent further temperatures  It may lead to the formation of medicine.
spread of cancer to  Refrain from using saturated of mutagenic and Edinburgh:
the peripheral body fats and use Omega-3 carcinogenic heterocyclic Churchill
systems polyunsaturated oils amines through the Livingstone.
 Offer folic acid interaction of muscle
supplementation creatinine with amino acids
Pericleous, M.,
 Offer foods with polyphenols as well as the formation of
Mandair, D., &
such as coffee, tea, and N-nitroso compounds.
Caplin, M., Diet
fruits Grilling, broiling or cooking
and supplements
 Zinc supplementation on coal can potentially
and their impact
 Provide foods with vitamin D induce these changes. Haem
on colorectal
and calcium in meat can act as a
cancer
nitrosating agent promoting
 the formation of N-nitroso
compounds.
 Studies demonstrated an
increase in risk of colorectal
cancer in people with higher
consumption of saturated fat
but confounding factors in
the food matrix such as red
meat and reduced intake of
dietary fiber. Epidemiological
studies and populations
consuming large numbers of
polyunsaturated fish oils
have been found to have
lower rates of colon cancer.
This has led to the
hypothesis that diets high in
n-3 fatty acids may reduce
the risk of colorectal cancer
 The observation that folic
 acid supplementation was
associated with a substantial
decrease in colon cancer
among patients with
ulcerative colitis led
researchers to examine the
role of folic acid in the
prevention of colorectal
cancer
 The most important dietary
sources of polyphenols are
fruits, vegetables, seeds, and
beverages such as fruit juice,
green tea, coffee, cocoa
drinks, red wine, and beer.
The chemoprotective role of
polyphenols against cancer
has been extensively
studied. Evidence from case-
control studies cell culture
 and animal studies have
shown a protective role
against colorectal malignancy
 Zinc supplementation may
positively influence tumor
cell response to anticancer
drugs by altering colonic
cancer cell gene expression
 Vitamin D and calcium are
thought to exert their
protective effects by
decreasing cell proliferation,
inhibiting angiogenesis,
stimulating apoptosis and
promoting cell differentiation

Sigmoidectomy,  Reinstitution of  High Protein  Replaces protein losses; Ruiz, A. J.,

colostomy, lymph feeding, control of  High Calorie increases resistance to Claudio, V. S., &
node resection glucose plasma,  Vitamin and mineral infection/maintenance of De Castro, E. E.
post-surgery attenuation of any supplementation immune status; promotes (2011). Medical
nutrition care metabolic stress  Liberal fluid intake wound healing; restores fluid Nutrition Therapy
response  Small, frequent feedings and electrolyte balance; For Filipinos(6th
 Provide balanced  Low fiber diet hastens return of muscular ed.). Metro Manila:
meals which will not strength; promotes blood- Merriam Webster
result in obstruction, building Bookstore.
gas pains, and  Promotes glycogen storage
unpleasant odors preventing ketosis; extra
energy for increased
metabolism; extra CHO
spares CHON
 Catalyzes metabolic reactions
in general; regulates fluid
and electrolytes; promotes
blood-building and blood-
clotting; prevents
dehydration and shock
during immediate
postoperative stage; replace
losses during surgery (e.g.
blood, drainage, sweat,
 vomiting, renal losses);
promotes wound healing
 Regulates fluid and
electrolyte balances;
transports nutrients and
oxygen and maintains skin
integrity; replace fluid losses
 Promote assimilation and
metabolism; flexible to
patient's tolerance for food
 Tough skins of fruits and
vegetables and high fiber
foods may cause stoma
obstruction and GIT
disturbance

Dyspnea  To alleviate  Encourage use of soft diet  Liquids are usually better Ruiz, A. J., Claudio,
symptoms of  Recommend small frequent tolerated than solids; cold V. S., & De Castro,
shortness of breath feedings spaced 2-3 hours; foods are better than hot E. E.
or difficulty of breath eat slowly foods (2011). Medical
  Encourage ice chips, frozen  For better tolerance and Nutrition Therapy
fruit juices, and popsicles absorption of food and to For Filipinos(6th
 Don't overload on CHO prevent overloading of the ed.). Metro Manila:
gut Merriam Webster
 These are often well Bookstore.
accepted
 This decreases carbon
dioxide retention and assists
in breathing.

Anorexia and  Provide food with as  To give foods which is  To correct nutrient deficiency Williams, S. R., &
cachexia much as density as nutrient dense by giving a and muscle wasting Schlenker, E. D.
possible so that high calorie and high CHON (2003). Essentials
"every bite will diet of nutrition and
count" diet therapy. St.
 To improve/ maintain Louis: Mosby.
patient's optimal
nutritional status and
body weight to
minimize the effects
  To maintain patient's
strength during
therapy and reduce
symptoms secondary
to therapy.
 To prevent
immunosuppression
 To provide long or
short term measures
to ensure survival
and functional status.

Anemia  To correct nutritional  To provide iron, vitamin B12,
anemia folic acid, and vitamin C.
 Provide high biological value
protein
 To prevent nutritional
anemia which the elderly are
particularly vulnerable to
 To supplement with vitamin
C that will aid in absorption
of iron
Williams, S. R., &
Schlenker, E. D.
(2003). Essentials
of nutrition and
diet therapy. St.
Louis: Mosby.

Hypokalemia  To treat the  Provide food rich in  To avoid deficiency of fluid Ruiz, A. J., &
 underlying cause potassium according to RENI and correct electrolyte Claudio, V. S.
such as vomiting, and maintains fluid and balance (2010). Basic
discontinued diuretic electrolyte balance.  To replace losses of Nutrition for
therapy or a electrolytes Filipinos(6th ed.).
potassium sparing Manila: Merriam &
diuretic Webster
 To correct and Bookstore.
prevent low serum
potassium in the Hayes, P. C., &
blood. Mackay, T. W.
(1992). Edinburgh
pocketbook of
medicine.
Edinburgh:
Churchill
Livingstone.

Hypocalcemia  To correct and  Provide food rich in calcium  To prevent muscle spasm The Merck manual
prevent low serum according to RENI and and low calcium levels in the of medical
 calcium in the blood maintains fluid and blood information.
electrolyte balance.  To hasten calcium absorption (1997). London:
 Take vitamin D supplements Merck Publications

Hypoalbuminemia  To replace protein  Provide foods with high  High biological value protein Ruiz, A. J., &
loss and correct low biological value protein contains all the essential Claudio, V. S.
serum albumin in the  Encourage eating egg whites amino acids (2010). Basic
blood  Egg whites are a rich source Nutrition for
of albumin Filipinos(6th ed.).
Manila: Merriam &
Webster
Bookstore.
Alkalosis  To correct respiratory  Treat the underlying cause;  To replace loss of acids in Hayes, P. C., &
alkalosis increase potassium the body through electrolyte Mackay, T. W.
supplementation or stop replacement (1992). Edinburgh
overzealous diuretic pocketbook of
administration medicine.
Edinburgh:
Churchill
Livingstone.
Faulty food habits  To correct faulty food  Small frequent feedings  To digest foods according to Ruiz, A. J., &
and lack of habits and to  Finger foods or eating out in tolerance Claudio, V. S.
thiamin in the diet increase dietary the patio  Requires less effort and are (2010). Basic
intake of thiamin  Serve the food attractively easier to handle; to welcome Nutrition for
by varying the shape, a change of environs Filipinos(6th ed.).
sauces, and plate for service  To stimulate appetite Manila: Merriam &
 Avoid highly seasoned foods  To avoid GI irritation Webster
and gas-forming foods in the  To avoid dehydration Bookstore.
evening
 Serve and encourage plain
drinking water
Alcohol intake  To have a lifestyle  Avoidance of alcohol intake  Frequent alcohol intake Ruiz, A. J., &
change of refraining  Education about the negative causes malnutrition in a way Claudio, V. S.
from alcohol drinking effects of alcohol that eating becomes (2010). Basic
 Spares the liver from inadequate and it is not Nutrition for
being overworked in efficiently utilized as a source Filipinos(6th ed.).
detoxifying alcohol in of energy or as a Manila: Merriam &
the blood physiological food source. Webster
The liver becomes Bookstore.
overworked in order to
metabolize and detoxify
alcohol.
i. Hospital Diet

The hospital diet consists of a high calorie, high protein, low fiber, and soft diet
given at small frequent feedings of 2-3 hour intervals. The elements of the menu
consists of foods rich in iron, potassium, calcium, zinc, B-complex vitamins,
vitamin A, vitamin C, vitamin D, folic acid, high biological value protein and
omega-3 fatty acids. The diet is non-irritating. Liberal fluid intake is given.

BODY MASS INDEX

Weight ∈kg 45 kg 45 kg
BMI = = = =19.4
Height ∈m2 1.152 2.31

FAO/WHO Classification: LOW NORMAL

DESIRABLE BODY WEIGHT

Method: Tannhauser's
¿ ( 5 ×12 )¿ 60 ×2.54¿ 152.4 cm−100¿ 52.4 kg¿ 52.4 kg−10 %¿ 47.16∨47 kg

DBW = 47kg

NOTE: The usual weight of the patient will be used due to the unavailability of
the actual weight. Due to severe weight loss and muscle wasting as evidenced
by the patient interview and patient profile, weight management is applied to
gradually achieve weight prior to hospitalization.

TOTAL ENERGY REQUIREMENT

Method: NDAP
¿ 45 kg ×30 PA¿ 1200 kcal/day + ( 100 % )
¿ 2400 kcal/day
TER = 2,400 kcal
PERCENTAGE DISTRIBUTION

CHON =2.0 g x 45=90 g

NPC=2400−( 90 x 4 )
¿ 2,040 kcalCHO=2040 x .60=1224 /4=306∨305 g FAT =2040 x .40=816/9=90.6∨90 g

DIET PRESCRIPTION

Diet Rx: 2,400 kcal; 305 g CHO; 90 g CHON; 90 g FAT

FOOD EXCHANGE LIST

No. of CHO (g) CHON (g) Fat (g) Energy

Ex. (kcal)
I.A. Veg A 2 3 1 - 16
I.B. Veg B 2 6 2 - 32
II. Fruit 3 30 - - 120
III. Milk 3 36 24 30 510
IV. Rice 9 207 18 - 900
V. Meat
LF 2 - 16 2 82
MF 2 - 16 12 172
HF 2 - 16 20 244
VI. Fat 5 - - 25 225
VII. Sugar 5 25 - - 100
TOTAL 307 93 89 2401

MEAL DISTRIBUTION TABLE

# B AM L PM D MN
I. A. 2 1 1
I. B. 2 1 1
II. 3 1 1 1
III. 3 1 1 1
IV. 9 2 2 2 2 1
V.
LF 2 1 1
MF 2 1 1
HF 2 1 1
VI. 5 1 1 1 1 1
VII. 5 1 1 1 1 1
ONE DAY SAMPLE MENU

FOOD SAMPLE FOOD NO. OF EX WT. IN APPROX.

GROUP GRAMS SERVING SIZE
BREAKFAST
Divided into 2 feedings: 6 AM & 8 AM
Veg A Chayote fruit, 1 45 1/2 cup cooked
boiled
Fruit Banana 1 40 1 (9x3 cm)
Milk Milk, powdered 1 30 1/4 cup
Rice Lugaw, thick 2 250 3 cups
consistency
MF Chicken egg, 1 60 1 pc
boiled
Sugar Sugar, white 1 5 1 tsp
Fat Peanut butter 1 10 2 tsps
Beverage 2 glasses water
 AM SNACK
10 AM
Rice sub Pan de sal 2 80 6 (5x5 cm)
HF Cheese, filled 1 50 1 slice (6x3x2
1/2 cm)
Sugar Pastillas, gatas 1 5 1 pc
Fat Avocado 1 65 1/2 of 12x7 cm
Beverage 1 glass water
LUNCH
Divided into 2 feedings: 12 NN & 2 PM
Veg A Malunggay 1 45 1/2 cup cooked
Veg B Baby corn 1 15 2 pcs 8 cm
long x 5 1/2
cm
circumference
Fruit Mango, ripe 1 60 1 slice (12x7
cm)
Rice Rice, soft 2 160 1 cup
cooked
LF Lean pork 1 30 1 matchbox
tenderloin slice
Sugar Pastillas, gatas 1 5 1 pc
Fat Avocado 1 65 1/2 of 12x7 cm
Beverage 2 glasses water
PM SNACK
4 PM
Milk Milk, powdered 1 30 1/4 cup
Rice sub Pan de sal 2 80 6 (5x5 cm)
HF Cheese, filled 1 50 1 slice (6x3x2
1/2 cm)
Sugar Sugar, white 1 5 1 tsp
Fat Peanut butter 1 10 2 tsps
Beverage 1 glass water
DINNER
Divided into 2 feedings: 6 PM & 8 PM
Veg B Sweet corn 1 20 2 tbsp
Fruit Banana 1 40 1 (9x3 cm)
Rice Rice, soft 1 80 1/2 cup
cooked
LF Lapu-lapu 1 35 1 slice
MF Egg, boiled 1 60 1 pc
Sugar Pastillas, gatas 1 5 1 pc
Fat Margarine 1 5 1tsp
Beverage 2 glasses water
MN SNACK
10 PM
Milk Milk, powdered 1 30 1/4 cup

Beverage 1 glass water

ii. Maintenance Diet

The maintenance diet consists of a high calorie, high protein, low fiber, and full
diet given at small frequent feedings of 2-3 hour intervals. The elements of the
menu consists of foods rich in iron, potassium, calcium, zinc, B-complex vitamins,
vitamin A, vitamin C, vitamin D, folic acid, high biological value protein and
omega-3 fatty acids. The diet is non-irritating. Liberal fluid intake is given. The
menu is adjusted to socio-economic status and food availability.

BODY MASS INDEX

Weight ∈kg 45 kg 45 kg
BMI = = = =19.4
Height ∈m2 1.152 2.31

FAO/WHO Classification: LOW NORMAL

DESIRABLE BODY WEIGHT

Method: Tannhauser's
¿ ( 5 ×12 )¿ 60 ×2.54¿ 152.4 cm−100¿ 52.4 kg¿ 52.4 kg−10 %¿ 47.16∨47 kg

DBW = 47kg

NOTE: The usual weight of the patient will be used due to the unavailability of
the actual weight. Due to severe weight loss and muscle wasting as evidenced
by the patient interview and patient profile, weight management is applied to
gradually achieve weight prior to hospitalization.
TOTAL ENERGY REQUIREMENT
Method: NDAP
¿ 45 kg ×35 PA¿ 1575 kcal ( 50 % )
¿ 2350 kcal
TER = 2,350 kcal

PERCENTAGE DISTRIBUTION
CHON =1.5 x 45=67.5 g∨70 g
NPC=2350−( 67.5 x 4 )
kcal kcal
¿ 2,080 CHO=2080 x .60=1248 =312∨310 g
day 4

kcal
FAT =2080 x . 40=832 =92.4 g∨90
9

DIET PRESCRIPTION

Diet Rx: 2,350 kcal; 310 g CHO; 70 g CHON; 90 g FAT

FOOD EXCHANGE LIST

No. of CHO (g) CHON (g) Fat (g) Energy

Ex. (kcal)
I.A. Veg A 4 6 2 - 32
I.B. Veg B 2 6 2 - 32
II. Fruit 3 30 - - 120
III. Milk 3 36 24 30 510
IV. Rice 9 207 18 - 900
V. Meat
LF 2 - 16 2 82
MF 3.5 - 28 21 208
HF - - - - -
VI. Fat 8 - - 40 360
VII. Sugar 6 30 - - 120
TOTAL 315 90 93 2364

MEAL DISTRIBUTION TABLE

# B AM L PM D MN
I. A. 4 2 1 1
I. B. 2 1 1
II. 3 1 1 1
III. 3 1 1 1
IV. 9 2 2 2 2 1
V.
LF 2 1 1 1
MF 3.5 1 1.5 1
HF -

VI. 8 1 2 1 3 1
VII. 6 1 2 1 1 1

ONE-DAY SAMPLE MENU

FOOD SAMPLE FOOD NO. OF EX WT. IN GRAMS APPROX.

GROUP SERVING SIZE
BREAKFAST
Divided into 2 feedings: 6 AM & 8 AM
Veg A Gabi leaves 2 45 1/2 cup cooked
Fruit Banana 1 40 1(9x3 cm)
Milk Milk, powdered 1 30 1/4 cup
Rice Rice, boiled 2 160 1 cup
LF Tuna sardines 1 50 1 1/2 of 6x4x3
cm each
MF Boiled chicken 1 60 1 piece
egg
Sugar Sugar, brown 1 5 1 tsp
Fat Fish oil 1 5 1 tsp
Beverage 2 glasses water
AM SNACK
10 AM
Milk Milk, powdered 1 30 1/4 cup
Rice sub Gabi, boiled 2 100 1/2 cup
Sugar Sugar, brown 1 5 1 tsp.
Fat Avocado 2 130 1/2 of 12x7 cm
each
Beverage 1 glass water
LUNCH
Divided into 2 feeings: 12 NN & 2 PM
Veg A Malunggay 1 45 1/2 cup cooked
leaves
Veg B Squash 1 45 1/2 cup cooked
Fruit Mango, ripe 1 60 1 slice
Rice Rice, boiled 2 160 1 cup
LF Chicken 1 80 1 slice, match
(laman) box size
MF Chicken egg 1.5 90 1 1/2 pcs
Fat Oil 1 5 1 tsp
Beverage 2 glasses water
PM SNACK
4 PM
Milk Milk for coffee 1 30 1/4 cup
Rice sub Pan de sal 2 80 6 pcs
Sugar Sugar, brown 1 5 1 tsp.
Fat Star margarine 3 15 3 tsp.
Beverage 1 glass water
DINNER
Divided into 2 feedings: 6 PM & 8 PM
Veg A Kang kong 1 45 1/2 cup cooked
Veg B Bisol 1 45 1/2 cup
Fruit Banana 1 40 1(9x3 cm)
Rice Rice, boiled 1 80 1/2 cup
LF Chicken gizzard 1 35 1/4 cup
Medium fat Chicken wings 1 25 1 med. or 2
small
Sugar Ice candy 1 100 1 pc
Fat Oil 1 5 1 tsp
Beverage 2 glasses water

C. Implementation

Due to the patient being in a state of hypercatabolism, with evident

signs of severe weight loss and muscle wasting, coupled with a post-surgery
dietary therapy needed, the patient is given a high calorie, high protein diet, with
vitamin and mineral supplementation, liberal fluid intake, and is encouraged to
take it in small, frequent feedings. The hospital diet was manipulated into a soft
consistency due to anorexia and dyspnea. The feeding should be spaced 2-3
hours apart, eaten slowly, and encouraged to eat ice chips, frozen fruit juiced,
and popsicles because these are well accepted for dyspnea. To correct the
anemia, the diet provides iron, vitamin C, vitamin B12, and folic acid. For the
hypokalemia, potassium-rich food like bananas was incorporated in the diet. For
the hypocalcemia, milk and milk products were incorporated in the diet. For the
hypoalbuminemia, eggs were incorporated in the diet. Some tips for feeding the
patient, taking into account her age and disease condition, are as follows:
 Eating out in the patio to welcome a change of environs
 Serving the food attractively to stimulate appetite
 Avoiding highly seasoned foods and gas-formers to avoid GI irritation
 Serving and encouraging plain drinking water to avoid dehydration
 Avoidance of alcohol and smoking
 Avoid cooking meat at high temperatures
 Refrain from using saturated fats and use Omega-3 polyunsaturated oils
 Offer folic acid supplementation
 Offer foods with polyphenols such as coffee, tea, and fruits
 Zinc supplementation
 Provide foods with vitamin D and calcium
 Provide high biological value protein

V. NUTRITION MONITORING

To monitor the progress of the patient, we would see to it that our

medical nutrition therapy is properly conducted and implemented through
contacting the client for a clearer and more specific intervention as well as to
clarify questions that the client would want to ask.

Weekly  Monitor the patient's tolerance

to each specific type of food and
change the diet accordingly
 Monitor the patient's ability to
 eat diet and see if there is a
difficulty chewing and
swallowing or if there is still
dyspnea
 Monitor patient's complete blood
count, blood gases, and clinical
chemistry through biochemical
assessment tests to see if there
are deficiencies or improvement
to existing deficiencies
 Check for percentage weight
gain every week
 Monitor daily fluid intake
 Monitor medicine intake and if
there are side effects, especially
regarding drug-nutrient
interactions
 Monitor the amount of activities
the client is involved with and
the intensity of stress from daily
activities.
Monthly  Observe the food changes:
amount, kind, type and variation
and prevent further eating
habits that would decrease the
beneficial progress of the
patient.
 Check laboratory results to
determine if there is progress or
changes of the results and to
 see if there is an improvement
to past deficiencies of certain
nutrients
 Check the extent of weight gain
and monitor if the patient has
achieved positive muscle mass
and desirable body weight
 FFQ table and FEL: Quality and
quantity of food and nutrient
intake

VI. NUTRITION EVALUATION

Domain Method Expected Outcome/s

Direct Nutrition  Regular maintenance  Prevent any further
Outcome: diet with high calories, complications that
high protein, vitamin- arose from cancer
mineral  Correcting nutritional
supplementation, and deficiencies caused by
liberal fluid intake the disease condition/s.
 The diet if consumed it
All of which would provide can help prolong and
adequate nutrients and as maintain the quality of
 well as it takes to life for the patient.
consideration the nutrients
that are needed to be
regulated in the disease
condition.
Clinical and Health To facilitate the recovery of  To ensure that the
Status Outcome: the patient. complications that
arose from the
patient's colon cancer
has subsided or
improved
 To ensure that the
needs of the disease
conditions are met.
Behavioral & Diet counseling  The patient will be able
Environmental to understand the
Status Outcome: rationale behind his
diet and accept the
foods she would eating
would be slightly
heavier and there
would be slight
changes in its texture
at the start before
transitioning back to a
regular diet to achieve
weight gain and to
correct nutritional
deficiencies.
 Evaluate if there is a
 lifestyle change like
avoidance of alcohol

CONCLUSION

Pre-admission, the patient's chief complaints were abdominal

distention, vomiting, nausea, dyspnea, body malaise, and constipation. Post-
operation diagnosis states that the patient has stage I colonic adenocarcinoma,
hence, a sigmoidectomy, colostomy, and lymph node resection were undergone.
The condition gave rise to complications ranging from hypokalemia,
hypocalcemia, hypoalbuminemia, anemia, lymphocytopenia, and neutrophilia, all
of which are interconnected to the patient's lifestyle and disease condition.
 The dietary management prescribed for her hospital diet consists of
a high calorie, high protein, low fiber, and soft diet given at small frequent
feedings of 2-3 hour intervals. The elements of the menu consists of foods rich in
iron, potassium, calcium, zinc, B-complex vitamins, vitamin A, vitamin C, vitamin
D, folic acid, high biological value protein and omega-3 fatty acids. The diet is
non-irritating. Liberal fluid intake is given. The maintenance diet is the same,
except with a manipulation of consistency from soft to regular and an
adjustment of the menu that would fit the socio-economic situation of the patient
and taking into consideration the proximity of her household to the municipality
center.
This nutrition care plan aims to provide the patient with the needed
micro and macronutrients according to her disease condition and to help prevent
further complications that may arise. The case study has fruitfully assessed her
current nutritional and physical status, diagnosed her disease conditions and
problems, created an intervention plan for dietary management, and have
formulated a monitoring and evaluation scheme to compare current nutritional
and physical status with expected outcomes.

REFLECTIONS

Kurt Abrio

This case study is really challenging that we have to sacrifice our

personal time and personal activities to make this case study successful, even
with the given hectic schedule in some of our subjects considering that it is
midterms week and do multitasking from studying to doing our case study. Our
minds were really put to work in making our case study and studying for the
midterm exams. The case study may be challenging but with the cooperation of
the group we were able to do the case study and overcome challenges and
problems that we faced in making the case study and through Christ who gives
us strength and the will to do the impossible.

Christian Denzel Sagun

The making of this case study was honestly an eye opening

experience even from the start. It was my first time to interview a real life
patient with cancer in a hospital and although it was a challenge to translate
difficult technical medical terms to gather data about the patient's condition, it
made me learn to sympathize and realize that not everyone is as privileged as
others. It made me sad that I had to hear about her living conditions and how
she had to travel more than a hundred kilometers to get medical attention and
treatment of her disease condition. The creation of the paper itself was a huge
challenge, from gathering library and online sources, to comprehensive research
of not only the main disease conditions but also the complications that arose
from it and how the pathophysiology are all interconnected. My group and I
spent so much time and sacrificed a lot of our personal activities to create a
comprehensive paper. At the end of the day, I realized that while we were
making case study, it's not about the grade but it's about utilizing all the
knowledge we gained on nutrition and dietetics in the past 5 semesters and
applying it into patient care. We had to be compassionate enough to maintain
attention to detail to make certain that the dietary management we prescribe to
the patient is beneficial to her well being and not detrimental to her health.
Ultimately, the values I learned during the creation of this case study will be
carried on not only in the succeeding case studies, but also in my other major
subjects.
Vince Somido

In this case study, we have put our best through Christ who
strengthens us. Since this is our first time having this kind of challenge, we
accepted the new challenge give upon us with open arms. Our group has done
many remarkable things. Those sleepless nights, eye bags to gain and coffees to
drink will all be worth it in the end. The days we've spent making our case study
will be memorable because it is the beginning and not the end of everything. Our
group functioned as one. Without cooperation, it wont progress at all. Though
we have met complications through the making of our case study, we still ended
and solved it together as a group. There will be always those times which
laziness and boredom strikes, but we will never go down because of it.
Cooperation, discipline, trust and teamwork are the key to this activity. Everyone
in the group should know and understand what they're doing because if one
member doesn't know it well, it might be the reason for a downfall on your
group. That's why we need mastery and understanding about our topic.

Jenevieve Tolentino

In this case study, we really worked hard and put all our effort and
time in this project, especially with God's guidance who sustained us all the way
to complete our work. I am thankful for our patient who participated willingly
and tried her best to answer all the questions despite of all her difficulties she
was facing. Though we had our difficult times and a lot of sleepless nights, I was
challenged to strive hard and do my best not just for my grade but also for my
group mates. With this case study, it really helped me understand some of
diseases and also learned new and mind blowing facts related to our case. For
me its not just about my grade but it also understanding what we are doing and
especially to help our patient. All those difficulties and struggles were all worth it
when we finished our case. I am thankful for God for enabling us to complete
this project and for my group mates who also put all their effort in this project.

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ACKNOWLEDGEMENT

We would like to acknowledge everyone who helped us in our making our

case study. Especially our ever loving and ever supportive parents that allowed
us to spend our nights at coffee shops or even the houses of our group mates
This case study helped us expanded our perspectives and knowledge about
Medical Nutrition Therapy especially on our case that will help us in our future
purposes.

Most of all, we would like to thank The Father Almighty that he guided us
through thick and thin in our case study making. Even though we struggled, he
is always there for us.

To Ms. Circee Monte de Ramos, thank you for being our clinical instructor.
You have shared most of your learning to us and we are very thankful for it. In
return, we will also share our learning to the people who needs help and teach
them what is right.

Everything we have done is dedicated to our patient and to God.