CASE 32 QUESTIONS

Case Questions
I. Understanding the Disease and Pathophysiology

1. Mr. Seyer has been diagnosed with cancer of the tongue, which is a type
of head and neck cancer. Head and neck cancers are categorized by the
area where they begin. Describe these primary areas.

The tongue cancer is a type of head and neck cancer, and it also referred to the
cancers of the upper aerodigestive tract. Its primary areas are the oral
cavity(which is lips and inside of the mouth, including the front portion of the
tongue, and the roof or floor of the mouth), the oropharynx(which is the back
portion of the tongue and the throat behind the oral cavity), the larynx, and the
esophagus. The head and neck cancer are comprising malignancies of these
primary area.

(Krause 2012, p.513)

2. What are the major risk factors for development of head and neck cancer?
Does Mr. Seyer’s medical record indicate that he has any of these risk
factors?

The major risk factors for development of the head and neck cancer are have a
high prevalence of alcohol abuse, a long-term tobacco use, substance abuse, and
significant weight loss. Base on Mr. Seyer’s medical record, it indicate have the risk
factor of long term tobacco use since he smoke 2 pack of tobacco per day, have
the risk of over-drinking of alcohol since he had one to two drink most nights of
the week, and have the risk of significant weight loss since he has noted an
approximately 30-pound weight loss over 5-6 months.

(Krause 2012, p.514)

(Nelms 2016, p.709)

3. Mr. Seyer’s biopsy results indicated an HPV positive tumor. What is HPV?
Does this imply a better or worse outcome?

The HPV stand for human papilloma virus, and it is the most common sexually
transmitted infection. The human papilloma virus is usually harmless and goes
away by itself, but infection of human papilloma virus is linked to oropharyngeal
and cervical cancer. It implies a worse outcome since HPV will increase the risk for
tongue cancer.

(Krause 2012, p.738)

Parenthood, P. (n.d.). What Is HPV & How Do You Get It? Retrieved September 26,
2020, from https://www.plannedparenthood.org/learn/stds-hiv-safer-sex/hpv

4. Mr. Seyer’s cancer was described as Stage IV T2 N2b. Explain this

terminology, which is used to describe staging for malignancies.

This terminology is called Tumor Node Metastases (TNM) Staging System, and it is
developed as a tool for doctors to stage different types of cancer based on certain
standards by The American Joint Committee on Cancer. The T category describes
the original tumor, and the tumor size is usually measured in centimeters or
millimeters. The number from T1 to T4 is using to describe the tumor size and
level of invasion into nearby structure, and T2 is representing that the cancer is
more than 2cm but less than 5 cm across. The category of N is described whether
or not the cancer has spread into nearby lymph nodes, and the number from N1 to
 N3 describe the size, location, and the number of lymph nodes involved. The N2b
is representing that more than one lymph node contain cancer cells on the same
side of the neck as the cancer. Stage IV would be a stage IV cancer, and stage IV
represent that this cancer is serious and has widespread to other part of body.

(Nelms 2016, p.709)

Mouth and oropharyngeal cancer. (2019, May 08). Retrieved September 26, 2020,
from https://www.cancerresearchuk.org/about-cancer/mouth-
cancer/stages-types-grades/TNM

5. Cancer is generally treated with a combination of therapies. These can

include surgical resection, radiation therapy, chemotherapy, and
immunotherapy. The type of malignancy and staging of the disease will, in
part, determine the types of therapies that are prescribed. Define and
describe each of these therapies. Briefly describe the mechanism for each.
In general, how do they act to treat a malignancy?

Surgical Resection: Surgical resection is referring to Surgery, and it is used in

cancer prevention, diagnosis, staging, treatment, palliation, rehabilitation. If an
individual has an increased risk of cancer, this therapy should be performed. The
surgical resection is removing the tumor or cancerous mass with scalpel and other
tools, and it is the effective mode of treatment because of 40% of cancer patients
are cured by this therapy. Even though the cancer has metastasized, it still can
improve the quality of life and permit adjuvant therapy by removing tumor.

Radiation therapy: it is used to cure the cancer as in Hodgkin’s disease,

testicular seminomas, thyroid carcinomas, localized cancers of the head and neck,
and cancers of the uterine cervix, and it also can be used to control malignant
disease which the tumor cannot use surgical resection or presenting of local nodal
metastasis. Radiation therapy is delivered with electromagnetic rays and charged
particles, and it can destroy cancer cell by altering cellular and nuclear material
such as DNA.

Chemotherapy: it is a systemic treatment and differs from surgery or radiation in

that it affects the whole body, and it can used alone or in combination with other
treatment. Chemotherapy are used to eradicate the cancer, control its size and
spread, and alleviate the symptoms. There are several different type of
chemotherapy like adjuvant chemotherapy, neoadjuvant chemotherapy, and
combination chemotherapy.

Immunotherapy: The Immunotherapy focus on enhancing patient’s own immune

system to attack cancer cells or providing specific substance which can enhance
the immune response. The mechanism can be done by synthesized interferons,
interleukins, and cytokines.

(Nelms 2016, p.708,710,711,712)

6. Mr. Seyer had a partial glossectomy and right neck dissection on 9/7.
Describe these surgical procedures. How may these procedures affect him
nutritionally?

The partial glossectomy is removing part of the tongue and sewing the remaining
part back together. The right neck dissection is an incision into the neck for
removing of lymph nodes which contain cancer cell. These procedures may affect
him nutritionally, and Mr. Seyer will swallow and chewing difficultly, cause pain,
and alter tasted after having these procedures. Therefore, these procedures may
lead him to lower food intake and diminished appetite, it also may cause him to
present with malnutrition

(Nelms 2016, p.709)

II. Understanding the Nutrition Therapy

7. Many cancer patients experience changes in nutritional status. Briefly

describe the potential effect of cancer on nutritional status.

The potential effect of cancer on nutritional status is about that inducing metabolic
changes which result in abnormal metabolism of carbohydrates, proteins, and
lipids, involuntary weight loss, muscle wasting, and decreasing quality of life. The
change of metabolism can potentially cause a combination of inflammatory
cytokines, hormones, insulin resistance, and factors that will impact proteolysis
and lipolysis. The catabolism and decreased protein synthesis which are caused by
cancer will deplete patient’s lean body mass, so the serious weight loss will occur.

(Nelms 2016, p.706)

8. Surgery, radiation, and chemotherapy affect nutritional status. Describe potential

nutritional and metabolic effects of these treatments.

Surgery: The Surgery will potentially impair normal digestion and absorption, and
it will cause patient to experience fatigue, and temporary changes in appetite and
bowel function that caused by anesthesia, and pain. The surgery in cancer
treatment also will lead to difficulty with chewing and swallowing, aspiration
potential, sore mouth and throat, Xerostomia, and alteration in taste and smell.
Moreover, the individual will require more protein and energy intake for
recovering.

Radiation: The radiation may lead patient to experienced fatigue, loss of appetite,
skin changes, and hair loss in the area being treated. The radiation for head and
neck caner cause acute effects such as xerostomia, mucositis, sore mouth and
throat, thick saliva/oral secretion, dysphagia, alterations in taste and smell. There
is also some late effect which will occur more than 90 days after treatment such as
mucosal atrophy and dryness, salivary glands, and osteoradionecrosis.

Chemotherapy: The potential effect of chemotherapy includes myelosuppression,

anemia, fatigue, nausea and vomiting, loss of appetite, mucositis, changes in taste
and smell, xerostomia, dysphagia, and altered bowel function. The severity of side
effect is depending on the specific agents used, dosage, duration of treatment,
number of treatment cycles, accompanying drugs, individual response, and
patient’s current health status.

(Krause 2012, p.743,746,747)

III. Nutrition Assessment

9. Calculate and evaluate Mr. Seyer’s %UBW and BMI.

Patient’s weight:198 lbs.=90kg, height:6’3” =1.9m

BMI=90kg/(1.9m)2=25kg/m2

His current body weight is 198 lbs., and his usual body weight is 228 lbs. since he
has note an approximately 30-pound weight loss over 5-6 months (198lbs.
+30lbs.=228lbs.).

%UBW=current body/UBW*100%=198/228*100%=87%
10. Summarize your findings regarding his weight status. Classify the severity
of his weight loss. What factors may have contributed to his weight loss?
Explain.

Base on Mr. Seyer’s BMI, I find out that he currently is in the health range since
His BMI is between the range of BMI 18.5-25kg/m^2. However, his %UBW is
about 87% of his normal body weight. Base on his medical report, we know that
he had an approximately 30-pound weight loss over 5-6 months. He lost about
13% of his UBW for one month, and so I will classify he had a very severe weight
loss. The factors that may have contributed to his weight loss are having a
significant pain with eating especially true with spicy or acidic foods, so this factor
will cause malnutrition for him. Secondly, the patient who had a cancer cause the
abnormality of metabolism of carbohydrate, protein, and fat, and this also can be
the factor cause his weight loss.

11. What does research tell us about the relationship between significant
weight loss and prognosis in cancer patients?

The research indicate that weight loss is a surrogate of malnutrition, and weight
loss is an indicator of poor prognosis in cancer patients. The weight loss has been
correlated with adverse outcomes such as increasing incidence and severity of
treatment side effect and increasing risk of infection which may reduce the chance
of patient to survive. Moreover, the weight loss also may cause by chemotherapy
and radiation since it will cause patient to experience the nausea and vomiting,
and loss of appetite. Therefore, these side effect also will cause patient to have a
significant weight loss.

(Nelms 2016, p.710,711)

Nutrition in Cancer Care (PDQ®)–Health Professional Version. (n.d.). Retrieved

September 27, 2020, from https://www.cancer.gov/about-
cancer/treatment/side-effects/appetite-loss/nutrition-hp-pdq

12. Estimate Mr. Seyer’s energy and protein requirements based on his
current weight.

Mifflin-St. Jeor/EER=10*90kg+6.25*190cm- 5*58+5=1802kcal/day

Total energy requirement is 1802kcal x 1.3=2343 kcal/day.

Protein Needs: 2343 kcal/day * 20%=469kcal/day 469/4=117g

13. Estimate Mr. Seyer’s fluid requirements based on his current weight.

Base on Mr. Seyer’s age, he is 58yrs, and recommendation for fluid intake about
30mL/kg.

90Kg * 30mL/kg = 2700mL

He should be getting 2700mL of fluid daily.

14. What factors noted in Mr. Seyer’s history and physical (as well as other
medical/nutritional history) may indicate problems with eating prior to
admission?

Mr. Seyer have tongue pain for several months that has progressive gotten worse,
and he had a “pimple” on his tongue which the mass seemed to slowly get worse.
He has a poor appetite, and he feels full quickly when eating. All of these may
indicate problem with eating prior to admission.

15. Mr. Seyer is currently receiving enteral nutrition, specifically Isosource HN

at 75 mL/hr per PEG tube.
 https://www.vitalitymedical.com/novartis-isosource-hn-1-2-cal-tube-feeding-
formula.html

a. Calculate the amount of energy and protein that will be provided at

this rate.

75mL/Hr * 24 hr= 1800mL

Amount of energy = 1.2kcal/mL * 1800mL =2160 Kcal
Protein is 2160*18%=389 kcal 389/4=97g protein

b. Next, by assessing the information in the intake/output record,

determine the actual amount of enteral nutrition he received on
September 11.

On the September 11, the actual amount of enteral nutrition he received

1735mL of formula via enteral nutrition.

1735 mL * 1.2kcal/mL=2082kcal
2082kcal * 0.18 = 375 kcal 375/4=94g protein

c. Compare this to his estimated nutrient requirements.

Mr. Seyer’s estimated energy requirement is about 2343kcal per day, and
he need 117g protein per day. His enteral nutrition does not supply
adequate calories and protein for his body needs.

d. Compare fluids required to fluids received. Is he meeting his fluid

requirements? How did you determine this? Why would you
evaluate his output when assessing his fluid intake?

Fluids required = 2700mL

Fluids received = 2400mL from I.V. + 150mL from flush =2550 mL
2700mL – 2550mL=150mL
Base on the data, Mr. Seyer need 150mL more of fluid per day to meet his
requirement of fluid intake. However, he has a positive fluid balance which
about 285 mL, so he may develop edema since he is holding water.
Therefore, we should monitor him more carefully, and the prescription of
his fluid should have some change.

16. What type of formula is Isosource HN? One of the residents taking care of
Mr. Seyer asks about a formula with a higher concentration of omega-3
fatty acids, antioxidants, arginine, and glutamine that could promote
healing after surgery. What does the evidence indicate regarding
nutritional needs for cancer patients and, in particular, nutrients to
promote postoperative wound healing? What formulas may meet this
profile? List them and discuss why you chose them.

Isosource HN is type of formula that high in protein and calorie when compare with
other type formula. In addition, Isosource HN also have a high concentration of
omega-3-fatty acid, antioxidants, arginine, and glutamine which could promote
healing after surgery. All of the protein source in Isosource HN is coming from Soy
protein. Mr. Seyer require a higher amount of energy and protein to promote
healing after surgery. Isosource 1.5 is designed for individuals with increase calorie
need and limited fluid tolerance, and it will meet the protein and calorie
 requirement for Mr. Seyer. However, it have relatively low Omega-3 than
Isosource HN, so this is the reason why insource HN is currently chosen.

(Nelms 2016, p.721)

17. Are any clinical signs of malnutrition noted in the patient’s admission
history and physical?

There are sign of malnutrition noted in the patient’s admission history and
physical. Firstly, he had 30lbs. weight loss over 5-6 months, and it is causing his
currently weight is 86% of his usual body weight. Secondly, his total protein,
albumin, and Prealbumin are lower than the health range base on his laboratory
repot, and these abnormal labs result also indicate a sign of malnutrition.

18. Review the patient’s chemistries upon admission. Identify any that are
abnormal and describe their clinical significance for this patient, including
the likely reason for each abnormality and its nutritional implications.

His protein total is 5.7g/dL which is lower than reference range 6-7.8 g/dL, his
albumin is 3.1 g/dL which is lower than reference range 3.5-5.5, and his
Prealbumin is 15g/dL which is lower than reference range 18-35 g/dL. Therefore,
the reason for these three abnormalities is low in protein intake, metabolic stress,
dehydration, and its nutritional implications are increasing protein intake, and
fluids intake. Then, I find his RBC is 4.2 (x10 6/mm3) is lower than reference range
about 4.5-6.2 for male, and this is caused by side effect of cancer. His Hemoglobin
is 13.5(Hgb, g/dL) which is lower than reference range for 14-17for male, his
hematocrit is 38(Hct, %) which is lower than reference range about 41-51 for
male. These two abnormal lab results are caused by low RBC, anemia,
dehydration, and its nutritional implications are increasing intake of energy, Iron,
fluids, Folate, and vitamin B12. Finally, his mean cell Hgb is 32.4pg which is higher
than reference range about 28-32, and this is caused by low RBC.

19. Mr. Seyer has been diagnosed with a life-threatening illness. What is the
definition of terminal illness?

The terminal illness is the disease or condition that can’t be cured, and it will lead
patient to die from the complication of the disease even though you have the
intervention.

What is terminal illness? Definition of terminal illness. (n.d.). Retrieved September

28, 2020, from https://www.mariecurie.org.uk/who/terminal-illness-
definition

20. The literature describes how a patient and his family may experience
varying levels of emotional response to a terminal illness. These may
include anger, denial, depression, and acceptance. How may this affect the
patient’s nutritional intake? How would you handle these components in
your nutritional care? What questions might you have for Mr. Seyer or his
family? List three.

Firstly, because of this patient have a significant pain with eating and a poor
appetite, this may cause him to have a hard time for having enough intake of
nutrients. Therefore, I will encourage him to eat more soft-texture food, non-spicy
or non-acidic food, and fluid food, and it will help him to improve the nutrient
intake. Secondly, he may feel depression and hopeless when he has a terminal
illness, and he will be lost motivation to eat properly. Therefore, I will encourage
him to have the idea that getting proper nutrient can help him improve his health
and prolong his life. I also will help him to accept the fact that he can never be
healthy anymore, and I will help him to create confidence to overcome depression
and fear.

Do you have any bad feeling when we increasing your food intake?
 Do you have any worry about why we increasing your food intake since it will
cause significant pain with eating?

Do you feel your quality of life be improved by getting proper nutrition?

IV. Nutrition Diagnosis

21. Select two high-priority nutrition problems after Mr. Seyer’s surgery and
complete the PES statement for each.

1. Malnutrition NI-1.4

Malnutrition related to decreased appetite and significant pain with eating as evidenced by
weight loss of 30lbs over 5-6months.

2. Inadequate protein intake NI-5.7.1

Inadequate protein intake related to inability to take food with adequate protein as
evidenced by low total protein, low prealbumin level, low albumin levels, and weight loss.

V. Nutrition Intervention

22. For each of the PES statements you have written, establish an ideal goal
(based on the signs and symptoms) and an appropriate intervention
(based on the etiology).

1. For PES of Malnutrition, the ideal goal is increasing his calorie intake to
3150kcal/per day. Base on his previous enteral nutrition formula, his calorie intake is
2083kcal, so he needs more calorie about 1067kacl/day to gain the weight back.

(For patient want to gain weight, we calculate by 30-35kcal/kg,

90kg*30kcal/kg=2700kcal – 90kg*35kcal/kg=3150kcal)

2. For PES of Inadequate protein intake, the ideal goal for increasing his protein
intake to 135g to help his level of total protein, prealbumin, albumin back to
normal range. Base on his previous enteral nutrition formula, his protein intake is
94g, and he needs more protein about 41g/day.

(For patient want to gain weight, we calculate by 1.5-2.5g/kg, 90kg*1.5g/kg=135g)

23. Does his current nutrition support meet his estimated nutritional needs?
If not, determine the recommended changes. Discuss any areas of
deficiency and ideas for implementing a new plan.

Base on his 24-hour recall, I use MyPlate App to calculate, and total calorie is
about 726kcal, and 98g carbs, 32g protein, 21g fat prior to hospital admission.
During his enteral nutrition, he received about 2016kcal of energy, and 97g
protein. Both 24-hour recall and enteral nutrition of Isosource HN 75mL did not
meet his estimated nutritional need.

The recommended change is changing his enteral nutrition formula to Isosource

HN 105mL/hr which can meet both calorie intake to 3150kcal per day, and 135g
protein per day.

Isosource HN 1.2kcal/mL at 105mL/hr

Fluid requirement= 105mL/hr*24hr=2520mL

 Total calorie= 105mL/hr* 24hr*1.2kcal/mL=3024kcal

Protein= (3024kcal *0.18)/4=136g of protein

136/90=1.5 g/body weight

When we are implementing a new plan, we need monitor Mr. Seyer very carefully,
and avoid him to have the refeeding syndrome since he is malnourished or in a
state of starvation before nutritional repletion. Therefore, the initial feeding should
be in a slow rate with careful progression, repleting all levels of electrolytes, and
assess serum electrolytes prior to feeding.

(Nelms 2016, p.152)

24. How may these interventions (from question #22) change as he

progresses postoperatively? Discuss how Mr. Seyer may transition from
enteral feeding to an oral diet.

When Mr. Seyer may transition from enteral feeding to an oral diet, his fist oral
diet should be liquid diet and nutrient dense shake. Then, he can have a small
portion of softened food with several times a day which can prevent nausea and
vomiting. Moreover, the patient will develop dehydrated easily after undergoing
radiation therapy. He should stay adequately hydrate, and he need avoid any drink
which contain caffeine. After the radiation, he also may develop dysgeusia which is
alteration in taste, and it will have a profound effect on a patient’s ability to ingest
an adequate amount of nutrition. Finally, multivitamin and mineral supplement
should also be taken since radiation therapies will cause deficiencies of vitamins
and mineral.

(Nelms 2016, p.716-722)

VI. Nutrition Monitoring and Evaluation

25. List the factors you should monitor for Mr. Seyer while he is receiving
enteral nutrition therapy.

While he is receiving enteral nutrition therapy, there are many factors that we
should monitor for him very carefully. Firstly, we need monitor his weight change
to ensure he is gaining weight. His intake/Output should also be monitored since
we need to know whether his formula is correctly used and whether he show
evidence of dehydration or overhydration. Moreover, we also need to monitor his
lab report about total protein, albumin and prealbumin, and make sure whether
they are low intake.

26. Mr. Seyer will receive radiation therapy and chemotherapy as an

outpatient. In question #8, you identified potential nutritional
complications with both. Choose one of these nutritional complications
and describe the nutrition intervention that would be appropriate for you
to recommend.

When Mr. Seyer receive radiation therapy, the potential nutritional complication
will be the dysgeusia which is alteration in taste. This taste change may include a
metallic taste, no taste sensation, a heightening of certain tastes, or aversions to
food. Patient who experience a metallic taste should avoid metal utensils, and use
plastic utensils instead, I will recommend him to incorporate other high-protein
food such as peanut butter, cottage cheese, cheese, poultry, and soy meat
substates into the diet.

(Nelms 2016, p.719)

27. Identify major assessment indices you would use to monitor his
nutritional status once he begins therapy.

Major assessment indices that I would use to monitor his nutritional status once he
begin therapy is Subjective Global Assessment (SGA). Our data will collect via PG-
SGA which include: “weight and weight changes information; history of anorexia,
changes in appetite, nausea and vomiting, diarrhea, constipation, abdominal pain,
early satiety, mouth sores (mucositis), taste changes, or dysphagia; the
individual’s ability to chew; and condition of the teeth, gums, and tongue”(Nelms
2016, p.715). SGA will gauge the patient’s perception of his own ability to
accomplish self-care.

(Nelms 2016, p.715)