MINI CASE

STUDY
ADVOCATE BROMENN MEDICAL COMPLEX
ASHLEY EDWARDS
FALL 2019
 OUTLINE

ASSESSMEN PMH MEDICAL TREATMENT MNT PROGNOSIS

T DIAGNOSIS
 ASSESSMENT: RB
• 55 yo Male
• 75 inches / 6’ 3”
• Admission date: 9/28
• Admission weight: 110 lbs.
• BMI: 13.7 kg/m²
• Unit: Medical Oncology
• Transferred from Eureka
• Patient presented to Eureka ED with:
• Weight loss
• Hoarseness of breath
• Weakness/lightheadedness
 Smokes pipe 3-4x/day

Alcohol dependence (quit ~1 year ago)

Delirium Tremens

Acid and Coke (over 10 ya)

PAST MEDICAL Appendectomy

HISTORY
Stabbed in the liver

Family Hx of: CAD, MI, Emphysema

Seizure – ER in 2009
 Diffuse metastatic Small Cell Lung Carcinoma
malignancy Never diagnosed before

Severe Malnutrition - Cancer Cachexia

CURRENT Dehydration

MEDICAL
DIAGNOSIS CIWA Protocol

Cystic lesion in L Basil Ganglia

Note: patient went into A-fib in the AM 9/29

Potential
Obesity & sedentary lifestyle
Inadequate FAVs intake
CANCER
causes: Excess intake of red/cured meats
Alcohol, Smoking/tobacco use

Over 50% experience

weight loss before dx
(AND)

Oncology pt. may have

Cachexia cachexia syndrome and
malnutrition
Syndrome 3 stages of Cancer Cachexia
 CANCER CACHEXIA

Pre-Cachexia Cachexia Refractory Cachexia

Early metabolic signs such • Ongoing loss of skeletal • Advanced cancer or pre-
as muscle mass (with or w/o terminal
loss of appetite loss of fat mass
• Rapidly progressive cancer
impaired glucose • Cannot be fully reversed
• Presence of factors making
intolerance through conventional
management no longer
involuntary weight loss nutrition support
possible or appropriate
of 5% • 50% experience sarcopenia
• Life expectancy of less
Dependent on:
• Characterized by: than 3 months
Type
• Weight loss > 5% OR
Stage
• BMI < 20 w/ WL >2%
Inflammation OR
Response to therapy • Sarcopenia & WL >2%
 SMALL CELL LUNG
CARCINOMA
• ~ 10 – 15% of all lung cancers (ACS)
• 70% of these pts will experience metastasis before dx (ACS)
• Tends to respond well to chemo and radiation (ACS)

• Typically caused by smoking

• Fast growing
• Metastasizes quickly throughout body
• Symptoms typically include
• Chest Pain
• SOB
• Cough
• Fatigue
• Weight loss
 LAB VALUES

• Blood Pressure
Refeeding:
• Highest of 165/97
• Typically trended around 130/80 • Potassium 3.1 (L) on 10/1
• BUN – 7 (L)
• Magnesium WNL
• Creatinine – 0.63 (L)
• Carcinoembryonic Ag – 32.9 (H) • Phosphorus WNL
• Hematology:
• Sodium WNL
• LOW
• RBC, Hgb, HCT, Lymph %, Mono %, and Lymph #
• HIGH
• Neut %, RDW
 MEDICAL TREATMENT

Cancer Afib Dehydration

Steroids PO Put on Cardiac Tele Started on NaCl
Recommended f/u with Dr. Echo – Resulted Normal,
Burr Cardiology signed off
 Hydromorphone HCl (Dilaudid)

• Opioid agonist analgesic

• Apnea, cardiac arrest
• Interactions: antihistamines, opioids
• Food Interactions:
• Causes reduced absorption of: Calcium,
Chromium, B6
• Loss of magnesium – may need
MEDICATIONS supplementation
Sertaline (Zoloft)

• Antidepressant
• Diarrhea, dry mouth, nausea
• Food Interactions:
• Replenish Sodium
• Chromium supplementation could help
depression (EAL)
• Avoid grapefruit (CYTP450)
 Hydroxyzine (Atarax)

• Antiemetic
• Constipation, dry mouth
• Interactions: Alcohol, opioids

Diltiazem HCl (Cardizem)

• Antianginal/ AntiHTN
• Edema, nausea
MEDICATIONS
Ondansetron HCl (Zofran)

• Antiemetic
• Diarrhea

Fentanyl Citrate (Sublimaze)

• Opioid
• Magnesium supplementation may decrease the amount
needed to manage pain
• Apples, Grapefruit, and Oranges decreases absorption
 Albuterol (Duoneb)

• Relaxes Resp. muscles to increase airflow

• May need to repleat: Ca+, Mg, K, phosphate
• Caution with soy allergies

Hydrocodone
Bitart/Acetaminophen

MEDICATIONS • Opioid
• N/V/D, dry mouth, constipation
• Interactions: other opioids, alcohol

Meperidine HCl (Demerol)

• Opioid
• Constipation, N/V
• Interactions: alcohol, morphine,
 Lorazepam (Ativan)

• Sedative, anxiety – CIWA Protocol?

• Dry mouth, nausea
• Interactions: alcohol

Prednisone
• Corticosteroid
• Edema, increased appetite
• Food Interactions:
MEDICATIONS • Replenish: Calcium, chromium, melatonin, potassium
selenium, B6
• May upset GI, increase fiber and water for constipation
• Chromium supplementation may decrease
corticosteroid-induced diabetes Vit. C, selenium and zinc
• Avoid pomegranate, grapefruit

Morphine Sulfate

• Opioid
• Bronchospasms, resp. system spasms, cardiac arrest, N/V,
constipation
• Interactions: alcohol
 Atropine Sulfate (atropine sulf)

• Anticholinergic, Tx Bradycardia
• Altered taste, dry mouth, N/V

Propofol (Diprivan)

MEDICATIONS • Sedative

Metoprolol Tartrate(Lopressor)

• antiHTN
• Resp. system spasms, N/V/D
• Interactions: NSAIDs
• May cause high blood K+ levels
 • Ensure Breakfast and Lunch per MST
Regular/General policy
Diet • Patient agreed to try Ensure

• Patient experiencing nausea & ↓

appetite
Diet Recall • Patient reported consuming < 50% usual
intake for 1 month INITIAL
Patient reported • CW: 110 lbs. BMI = 13.7 NUTRITION
UBW: 165 lbs. 1
year ago
• 55 lb. (33%) wt. loss in one year
• 35 lb. (24%) in last month ASSESSMENT

Physical • Deferred d/t patient discomfort 9/30

assessment • Patient obviously cachectic visually

• Severe Acute Malnutrition, High 1-4 days

• Long Term kcal needs: 35 – 40 kcal/kg
Nutrition Dx: • Protein 20% est. needs
• Refeeding Needs calculated
 Diet:
• Patient reports increased appetite
• Eating 3 meals/day most days
• Per EMR, patient consuming 75% est. needs
• Tolerating Ensures
Weight:
FOLLOW UP: • 118.4 lbs. on 10/4, 7% weight change

10/4 • Recalculated kcal needs appropriately

• Note: 60% IBW

Obtained Physical Assessment:

• Severe in all categories
• Confirmed severe fat and muscle loss

Other:
• Last BM 10/3
• Educated: Increasing calories at home, ensure
coupon
 PROGNOSIS

Discharge to NH, possibly to IN to live with sister in 2 mo

Home Meds
Hydrocodone – Sennosides Docusate
Acetaminophen, 1 Q6H
Morphine Sulfate, BID
Sodium, - Opioid Prednisone for 10 days

F/U with Nephrology, Neurology

Chemoimmunotherapy
 • Chronic over acute malnutrition
• Refeeding needs at 1.2g instead of 20%
• Protein needs would have changed from 37.5 – 50
g/day (20%) to 59 g/day
WHAT I WOULD • Monitored patient for refeeding more closely
HAVE DONE • Researched Medications more thoroughly
DIFFERENTLY • Provided more nutrition education and
thoroughly educating on meeting calorie needs
• Dietary supplements or medical food
supplements (MFS) containing eicosapentaenoic
acid (EPA) to help stabilize weight (EAL)
QUESTIONS?
 REFERENCES
Academy of Nutrition and Dietetics ( 2019). Nutrition Care Manual . https://www.nutritioncaremanual.org

American Cancer Society (2019). What is Lung Cancer.

https://www.cancer.org/content/cancer/en/cancer/lung-cancer/about/what-is.html#written_by

Karch, A. M. (2019). 2019 Lippincott pocket drug guide for nurses. Philadelphia: Wolters Kluwer.

Escott-Stump, S (2015). Nutrition and Diagnosis-Related Care (8th ed.). Philadelphia, PA: Wolters Kluwer.

 Kaiser Foundation Health Plan of Washington (2019). Drug Information.

https://wa.kaiserpermanente.org/kbase/topic.jhtml?docId=hn-10000670