UConn Health

Nutrition Care Plan

Presentation
PATIENT: P.A.
BY: SCARLETT BALL
 INTRODUCTION TO P.A
• 66 yr. old Male
• Admitted 9/13/23
• Married
• Diagnosed with multiple myeloma in 2017
• Treatments have been unsuccessful
• Active bleed in leg
• He likes to cook
 MEDICAL HISTORY
• Multiple Myeloma (w/o remission)- cancer that forms in a type

of WBC called a Plasma Cell (make antibodies), found in bone

marrow. *can cause bone pain, thinning bones, and broken bones*

• Thrombocytopenia

• Osteonecrosis: Blood flow to the jawbone is disrupted, leading to

jawbone exposed and not covered by gums and the bones

weakens and dies.

• Hematoma of the Right Lower Extremity

• Schizoaffective Disorder
 ADMISSION DIAGNOSIS/
COURSE OF HOSPITALIZATION

ADMISSION- 9/13/23 Treatments

• Diagnosed in 2017 • Talquetamab
• Receiving 2 units of RBC
• Hospital Diagnosis: Multiple • Lactated Ringers/ IV – replace
water loss and electrolyte loss
Myeloma without Remission
• Why in Hospital?
First cycle of Talquetamab with
step up dosing
 ANTHROPROMETRICS
• 69” (175.3 cm)
• Admit Weight: 144 lbs. (65.6kg)
• BMI: 21.35 kg/m^2
• IBW: 155 lbs. (70. 7 kg)
• UBW: 151 lbs. (68.5 kg)
8/17 -> 9/14 = -7.09%
weight loss in one month
Patient Weight History
5/1/23 – 154LBS
5/18/23 - 144 LBS -6.49%
-3.89%
6/12/23 - 148 LBS
7/17/23 - 152 LBS +1.3%
8/17/23 = 155 LBS +0.65%
9/5/23= 145 LBS -5.84%
9/14/23= 144 LBS -6.48%
 LABORATORY DATA
Name of Lab Normal Range Patients Value/s Date/s
Neutrophils 40-70% 82, 87 9/13, 9/14 Immune System’s 1st Line of Defense

Lymphocytes 20-50% 0,12 9/13, 9/14 Multiple Myeloma cancer that

forms in WBC-> therefore
Monocytes 4-12 % 3 9/13 abnormal antibodies destroys
RBC 3.8- 5.20 uL 1.73 9/14 good antibodies

Hematocrit/ 40-52%/ 13.0- 15.1/ 5.1, 17.7/ 6.1 9/13, 9/14

Hemoglobin 18g/dL Low b/c of active bleed in leg as well as
abnormal plasma cells are multiplying
WBC 3.8- 10.6 uL 3.6, 1.8 9/13, 9/14
Prothrombin 10.4- 13.0 sec 16.9 9/14
Thrombocytopenia – due to MM
Platelet 150-440 16, 12 9/13, 9/14
Sodium 137- 144 mmol/L 134, 135 9/13, 9/14 Not eating enough

Active bleed in leg

CO2 23-32 mmol/L 17, 18 9/13, 9/14
Kidney and Liver not functioning
AST 17-35 U/L 38, 36 9/13, 9/14 properly due to the cancer -> M- spike
proteins and the chemotherapy
BUN 8-24 mg/ dL 40, 37 9/13, 9/14
Multiple Myeloma makes abnormal
Total Protein 6.2- 8.1 9.6, 8.6 9/13, 9/14 protein: M-spike protein
 KEY MEDICATIONS
DRUG NAME CATEGORY How it works, why /when use Side Effects
Talquetamab Chemotherapy is a humanized monoclonal antibody used for Weight loss (62%), decreased blood cell count,
the treatment of multiple myeloma. infections, liver problems

Hydromorphone Opioid used to treat moderate to severe pain. Loss of appetite, dizziness, tiredness, severe
weakness or drowsiness

Chlorhexidine Antiseptic a prescription germicidal mouthwash that Changes in taste, increase in tartar, staining of
decreases bacteria in your mouth. teeth

Risperidone Antipsychotic medicine an antipsychotic medicine that works by Agitation, anxiety, constipation, drowsiness,
changing the effects of chemicals in the brain. nausea
And is used to treat schizophrenia.

Compazine Anti-psychotic used to treat nervous, emotional, and mental Drowsiness, dizziness, light headiness, blurred
conditions (eg, schizophrenia) and non- vision, constipation or dry mouth
psychotic anxiety. It is also used to control
severe nausea and vomiting.
 NUTRITIONAL REQUIREMENTS

• Calories: 2,122.4 (Mifflin)= Maintenance

⚬ SF= 1.5 (cancer cachexia)
⚬ 30-35 kcal/kg = 1968 kcal- 2,296 kcal
⚬ Protein g/kg:= 2.0g *65.6 kg= 131 g
• Fluid: 30mL/ 65.6kg= 1,986 mL ~ 2L
 DIET ORDER

Current: Unrestricted, regular texture, thin liquids ,and double portions

diet.

Assessment of the appropriateness of the current diet order:

APPROPRIATE, but I would also add ->
Prosource 2X Day (mixed with choice of drink)

Why Appropriate?
P.A. is suffering from multiple myeloma, which has led to unintended
weight loss and a decrease in appetite.
 ASSESSMENT OF INTAKE

• PTA and at Hospital -> Poor Intake and Decreased Appetite

• PTA oral intake for the past month is around 1,500 Kcal, which is
less than 75% of his oral intake (stated in interview)
• In general likes a lot of protein foods and doesn’t eat enough
fruits and vegetables.
• Doesn’t drink Ensure as wife was not keen on them, thinks they
are too artificial.
NUTRITION-FOCUSED PHYSICAL FINDINGS
• Ill appearing and thin
• Leg swelling in his left leg
• Prominent clavicle
• Hollow depressions by the eye
• Fat and muscle wasting (as stated in interview)
• Due to his osteonecrosis some discomfort in lower right
jaw
• The Chlorhexidine eases the pain and doesn’t have
trouble eating
 DIAGNOSIS

Severe malnutrition related to cancer treatment decreasing

appetite/oral intake as evidenced by unintentional weight
loss of 7.09% in one-month, estimated calorie intake of only
1,500 calories for one month, and prominent clavicle region,
and hollow depressions by the eye.
 INTERVENTION
Regular Diet, Double Portions, Prosource 2x a Day
• Increase calories to 2,300 kcal
and 131g of protein
• Prosource 2x a Day= 15g Protein,
60 calories, Sugar Free
• Educated P.A. and wife on a High
Protein, High-Calorie die-> gain
weight, fat and muscle, regain
strength and recover from side
effects of chemo.
• Educated the benefits of
eating antioxidant rich fruits
and veggies to fight free
radicals.
• Defer him to PT to gain
back/ increase muscle mass
and strength.
• W/O muscle ->
increased risk for
falls and fractures
 MEAL
PLAN

25%- Protein
30% - Fat
45% - Carbohydrates
 MONITOR/ EVALUATION
• Consume at least 75% of double portion meals
• Increase protein to 131g of protein to increase muscle mass
• Consume 2 Prosource liquid proteins a day, with drink of choice
• Monitor weight at 1-month assessment (at least 3-4 pounds gained) to return to IBW, and follow up every
month for next 6 months
• Monitor muscle mass at 1-month assessment and follow up every month for the next 6 months
• Monitor BMI at one month assessment follow up every month for the next 6 months
• Monitor sodium levels to make sure they return to normal at 1-month assessment
• Monitor BUN and AST to make sure kidney and liver are function properly at 1- month assessment
• Monitor his chewing and check in on his mandible to see if that is affecting his desire to eat- 1 month
• Patients can identify three antioxidant rich fruits at 1- month assessment and is incorporating into diet
 WHAT I WOULD DO DIFFERENTLY THE
NEXT TIME?

• A full NFPE
• Other than that, I think I did a really good
job talking with wife and P.A. to meet his
needs finding an ONS like Prosource rather
than Ensure.
• Chris told Dietitian on staff to order it
to room
 Impact of resistance training on body composition and metabolic
syndrome variables during androgen deprivation therapy for
prostate cancer: a pilot randomized controlled trial

Background: Methods: 4 groups, RCT

o Prostate cancer patients on androgen deprivation
therapy (ADT) experience adverse effects such as
lean mass loss, known as sarcopenia, fat gain, and
changes in cardiometabolic factors that increase
risk of metabolic syndrome (MetS).
o Resistance training can increase lean mass,
reduce body fat, and improve physical
function and quality of life.
Goal of study:
Does a combined approach of training and
protein supplementation elicit greater changes
in body composition -> Primary outcome (lean
body mass)
1. Resistance training and protein
supplementation (EXE)- exercise 3 days per
week for 12 weeks, received 50 g Whey
Protein
2. Resistance training (EXE)- exercise 3 days
per week for 12 weeks
3. Protein supplementation (noEXE) - 50g of
Whey protein)
4. Control Stretching (noEXE)
o 37 Participants Randomized
o (EXE n = 13; NoEXE n = 19)= 31 followed through
o 43.8% of participants were sarcopenic and
40.6% met the criteria for MetS (3 of 5
components met)
 Continued

Results:
Clinical application
*The addition of protein alone did not offer
additional benefit in improving body *Protein alone will not
composition increase muscle mass.
o The EXE group significantly increased muscle mass Strength training must be
compared to the NoEXE group as reflected by lean
involved to promote muscle
mass ( EXE 2.2% vs NoEXE 0.2%, p = 0.05, d = 0.9)
o Increased Appendicular skeletal mass (EXE 3.4% vs growth in cancer patients
NoEXE 0.2%, p = 0.03, d = 0.9
o Increased Sarcopenic Index (EXE 3.6% vs NoEXE P.A. must incorporate Physical
Therapy into his ADL’s
0.1%, p = 0.02, d = 1.0).
o After 12 weeks, no significant differences were
observed between EXE and NoEXE for insulin, HOMA-
IR or any MetS variables except for waist
circumference, decreased significantly in EXE
compared to NoEXE (EXE -1.1%, NoEXE 2.0%, p = 0.013,
d = 0.9).
 REFERENCES
Academy of Nutrition and Dietetics. Nutrition Care Manual. [High Calorie, High Protein].
[https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=509]. Accessed [September 18,
2023].

Drugs.com [Internet]. Chlorhexidine Topical Information from Drugs.com; c1996-2018 [Updated: 3

September 2023, Cited: 18 September 2023]. Available from: https://www.drugs.com/mtm/chlorhexidine-
topical.html#side-effects

Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language
for Nutrition Care. http://www.ncpro.org. Accessed [September 19, 2023]

Dawson JK, Dorff TB, Todd Schroeder E, Lane CJ, Gross ME, Dieli-Conwright CM. Impact of resistance
training on body composition and metabolic syndrome variables during androgen deprivation therapy for
prostate cancer: a pilot randomized controlled trial. BMC Cancer. 2018 Apr 3;18(1):368. doi: 10.1186/s12885-
018-4306-9. PMID: 29614993; PMCID: PMC5883585.
ANY QUESTIONS?