Semester: Spring 2016 Class: Medical Nutrition Therapy (NUTR 438B) Section: 1 Group: 5
Brief Description of the Case
Patient is a retired 68-year-old male admitted to acute care for possible dehydration, weight loss,
generalized weakness, and malnutrition. Patient complains of weakness, lack of energy, and states that he
gets full easily and never feels hungry. He was diagnosed with squamous cell carcinoma of the tongue
five years ago and had a partial glossectomy. Patient was treated with radiation therapy but has not
received treatment in the last 3 years. Medical history consists of essential hypertension, hyperlipidemia,
peripheral vascular disease, and weight loss of 60 lbs. in the last 2 years. Patient has chronic
inflammation; therefore, his condition is considered chronic disease-related malnutrition. Nutrition
intervention is important to rescue the body from distress by providing adequate amounts of vitamins and
minerals as well as overall adequate energy intake.
Summary of the Disease Condition
Definition
Malnutrition is any nutritional imbalance, as observed in undernutrition or overnutrition. However,
malnutrition typically refers to undernutrition. Unintentional weight loss is the most common feature of
disease related malnutrition. The proposed overarching definition for malnutrition is a decline in lean
body mass with the potential to affect molecular, physiological, and gross motor functions (White,
Guenter, Jensen, Malone, & Schofield, 2012).
Epidemiology
According to the World Health Organization, malnutrition is prevalent in 20-60% of the population
(Imoberdorf & Ballmer, 2014). In a study conducted on cancer patients alone, the prevalence of
malnutrition was 30.9%. Besides examining the fact that oncology patients are at heightened risk for
malnutrition, the study also stated that those with head and neck cancers (which includes oral), are
especially at risk for malnutrition (Pressoir et al.).
Etiology
Malnutrition is a result of an imbalance of nutrients and energy provided to the body relative to its needs
(Alberda, Graf, & McCargar, 2006). Malnutrition risk increases with age or with illness. Adult
undernutrition occurs along a continuum of inadequate intake and/or increased requirements, impaired
absorption, altered transport, and altered nutrient utilization (White et al., 2012). Simply put,
malnutrition is due to an inadequate intake or assimilation of nutrients within the body. In order for
malnutrition to be diagnosed, an interpretation of past food and nutrient history, recent intake records, and
a comparison of estimated versus actual needs must be assessed. It is also often accompanied by weight
loss, noted changes in performed physical exams, loss of subcutaneous fat, a loss of muscle mass, the
presence of edema, and reduced grip strength (Nelms, Sucher, & Lacey, 2015). Oncology patients are at
high risk for malnutrition given their changes in taste and loss of appetite.
Pathophysiology
The most severe nutrition problem for malnutrition is inadequate oral intake. Patient is at risk of
malnutrition if dietary intake is impaired. Inadequate intake may be caused by common pre-existing
conditions such as organ diseases, chronic infections, cancer, and digestive disorders (Hssain, Souweine,
& Cano, 2010). Depletion of body cell mass results from reduced intake or assimilation of energy and/or
protein. Inflammation also promotes catabolism of skeletal muscle that is least in part cytokine mediated
(Jensen, et al., 2010).
Specific Examinations including Lab Indicators and Medical Diagnosis:
According to American Society for Parenteral and Enteral Nutrition (ASPEN) and the Academy of
Nutrition and Dietetics (AND), there are characteristics that may be examined to diagnose and detect
malnutrition (White et al., 2012). Such characteristics include: insufficient energy intake, weight loss, loss
of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation that may sometimes
mask weight loss, and diminished functional status as measured by hand grip strength. Only two or more
out of six of these characteristics need to be present in order for diagnosis (White et al., 2012). C-Reactive
Protein (CRP) is an inflammation contributor to malnutrition syndromes. Hemoglobin (HgB) are known
to transfer oxygen to cells, therefore the value is low when related to protein-energy malnutrition.
Transferrin, prealbumin, albumin, and BUN levels also decrease in malnutrition (Hssain et al., 2010).
Updated 1/2015, Long Wang
Medical Treatment
Currently, the typical form of treatment of malnutrition is through the use of commercial nutritional
supplements. Oral nutritional support has been shown to reduce the risk of morbidity and mortality in
older, hospitalized adults. Other forms of treatment include selective mid-meal trolley interventions. This
allows patients to choose snacks they desire from a passing trolley, in the hopes of increasing their overall
energy intake as they are familiar with the options available. This method is also used in the treatment of
malnourished pediatric patients. Another form of treatment is a dose feeding or MedPass program that
requires that a nutrient-dense formula of 2 mL/kcal be prescribed, delivered to the patient in small
dosages several times a day, and is indicated on the patients medical charts (Campbell, Webb, Vivanti,
Varghese, & Ferguson, 2013).
References Cited in This Summary
Alberda, C., Graf, A., McCargar, L. (2006). Malnutrition: etiology, consequences, and assessment of a
patient at risk. Best Pract Res Clin Gastroenterol, 20(3), 419-39.
Campbell, K. L., Webb, L., Vivanti, A., Varghese, P., & Ferguson, M. (2013). Comparison of three
interventions in the treatment of malnutrition in hospitalised older adults: A clinical trial.
Nutrition & Dietetics, 70(4), 325-331. doi:10.1111/1747-0080.12008
Hssain, A., Souweine, B., Cano, N. (2010). Pathophysiology of Resuscitation Malnutrition. Reanimation,
19, 423-430. doi:10.1016/ j.reaurg.2010.06.009
Jensen L. G., Mirtallo, J., Compher, C., Dhaliwal, R., Forbes, F., Hardy, G., & Waitzberg, D. (2010).
Adult Starvation and Disease-Related Malnutrition A Proposal for Etiology-Based Diagnosis in
the Clinical Practice Setting From the International Consensus Guideline Committee. Journal of
Parenteral and Enteral Nutrition. doi:10.1016/j.clnu.2009.11.010
Imoberdorf, R., Ballmer, P., (2014). Epidemiology of Malnutrition. Therapeutische Umsche, 71, 123-126.
doi:1024/0040-5930/a000492
Nelms, M., Sucher, K., Lacey, K., & Roth, S. L. (2016). Nutrition therapy and pathophysiology (3rd ed.).
Boston, MA: Cengage Learning
Pressoir, M., Desn, S., Berchery, D., Rossignol, G., Poiree, B., Meslier, M., & ... Bachmann, P. (2010).
Prevalence, risk factors and clinical implications of malnutrition in French Comprehensive
Cancer Centres. British Journal Of Cancer, 102(6), 966-971.
White, J., Guenter, P., Jensen, G., Malone A., & Schofield, M. (2012). Consensus Statement of the
Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition:
Characteristics Recommended for the Identification and Documentation Of Adult Malnutrition
(Undernutrition). Journal of the Academy of Nutrition and Dietetics, 112(5), 730-738.
doi:10.1016/j.jand.2012.03.012
Biochemical
data, medical
tests, and
procedures
Lab data (e.g.,
electrolytes,
glucose) and tests
(e.g. gastric
emptying time,
resting metabolic
rate)
Nutrition Knowledge:
Physical Activity:
Food Availability:
Food Preferences:
Diet Hx:
Tobacco Use:
Alcohol Use:
Medications:
Comparative Standards
Energy:
UBW:
CBW:
25-30 kcal/kg:
Protein:
1.2 g/kg:
Updated 1/2015, Long Wang
Anthropometric
Measurements
Nutritionrelated Physical
Findings
Client History
Height, weight,
body mass
index(BMI),
growth pattern
indices/percentile
tanks, and weight
history
Physical
appearance,
muscle and fat
wasting, swallow
function, appetite,
and affect
Personal history,
medical/health/fam
ily history,
treatments and
complementary/alt
ernative medicine
use, and social
history
220 lb = 100 kg
156 lb = 71 kg
71 kg x 25 kcal = 1775 kcal
71 kg x 30 kcal = 2130 kcal
1.2 g x 71 kg = 85 g PRO
5.
Client history
Client History
Patient will have to shop for, prepare, and cook his food
with his wife or his wife will be his caretaker. Education
to his wife will also be needed.
Medication:
Lipitor 80mg daily
Capoten 25mg 2x/day
New medication order:
Thiamin injection 100 mg/day
Multivitamin capsule 1 Cap/day
Metronidazole 500 mg in NaCl
premix IVPB
Docusate capsule 100 mg 2x/day
Lipitor 80 mg daily
Lopressor 5 mg every 6 hours
specific textures of food. There were signs of impaired neurological strength; another criteria for the
diagnosis of malnutrition.
Problem:
Potential nutrition problems using NCP terminology:
Inadequate fluid intake NI-3.1
Unintended weight loss NC-3.2
Inadequate protein intake NI-5.7.1
Inadequate protein-energy intake NI-5.3
Inadequate oral intake NI-2.1
Malnutrition NI-5.2
Chronic disease or condition related malnutrition NI-5.2.2
Inadequate energy intake NI-1.2
Involuntary weight loss
Swallowing difficulty NC-1.1
Biting/chewing (masticatory) difficulty NC-1.2
Etiology: What caused or contributed to these problems?
Potential causes using NCP terminology:
Inability to manage self-care NB-2.3
Poor nutrition quality of life NB-2.5
Limited adherence to nutrition-related recommendations NB-1.6
Signs and symptoms: What evidence shows that there is a problem? How do you know there is a
problem? These are also your monitoring and evaluation parameters.
Anthropometric measurements: 70.9% UBW and lost 29% UBW over the past 2 years.
Nutrition Related Physical Findings: Exhibits temporal wasting, reduced strength, decreased muscle
tone, quadriceps and gastrocnemius: loss of lean mass, 1+ Pedal edema, and Hypoactive bowel sounds.
Food/Nutrition Related History: Consumes on average 789 kcal/day when needs are at 2130 kcal/day.
He reports feeling satiated prematurely and lack of appetite related to cancer treatments for primary
tongue squamous cell carcinoma. Patient was prescribed a mechanical soft diet.
Client History: Smokes 1ppd for 60+ years and drinks 1-3 cans of beer/day which may cause olfactory
impairment (loss of taste and smell). He has had partial glossectomy which may interfere with ability to
chew/move food around in mouth.
Biochemical data, medical tests, and procedures: Ketones positive while patient does not have diabetes
may be symptom of muscle wasting. Lab values of total protein 5.8, albumin 1.8, prealbumin 9 resulting
from limited energy intake.
PES Statement 1
Problem
R/T
Etiology
AEB
and CBW of 160lb (60 lbs. lost within the last 2 years).
PES Statement 2
Problem
Malnutrition NI-5.2
R/T
Etiology
AEB
Please summarize the relevant evidence regarding nutrition therapy of the disease conditions.
Please indicate the source of the evidence.
The EAL recommends RDs to use medical food supplements to help enhance the protein and energy
status of oncology patients who suffer from head or neck cancers (including oral), as these patients are
prone to malnutrition. Providing medical food supplements has shown to reduce risk of weight loss and
risk of mucosal damage. Furthermore, it is considered a grade 1 recommendation to provide a medical
food supplement containing fish oil as it has been shown to increase lean mass in oncology patients
(EAL). Protein needs for those who have head and neck cancers who have undergone radiation therapy
are significantly higher than that of the RDA for those of their weight (EAL).
Describe the nutrition intervention using approved NCP terminology (eNCPT).
Food and/or nutrient delivery: Modify composition of meals and snacks. (ND-1.2)
It has been determined that the patient would benefit from a puree diet due to prior glossectomy, which
may interfere with ability to chew/move food around in mouth. Patient will receive 5 small meals
throughout the day and 2 fish oil capsules to help increase lean body mass. Medical food supplements,
such as Ensure, in different flavors and forms will be given to patient to increase energy intake to treat
malnutrition. A diet plan has been formulated to increase energy, carbohydrate, protein, fat, vitamins, and
minerals intake and to inhibit the presence of ketones in the urine. This diet plan will also increase fluid
intake to meet nutritional requirements and improve lab results. If lab results of sodium, chloride, BUN,
and creatinine does not improve from hydration, another intervention will be needed to address those
issues. An appetite stimulant may be requested from MD if dietary intake does not improve.
Nutrition Education: Nutrition relationship to health/disease. (E-1.4)
Nutrition education is provided to patient and patients wife about malnutrition, which may be due to
radiation therapy patient received 3 years prior. Inform patient that muscle wasting correlates with low
levels of physical activity and food intake along with age-associated physiological changes, and lean body
mass is imperative in geriatrics (Brown et al., 2011, p. 459-460). Educate them on various medical food
supplements and other ways in consuming these supplements will become more appealing to patient
(milkshake, smoothie, and pudding). Providing handouts and web addresses about malnutrition after a
glossectomy and in geriatrics may be helpful in getting started and making it easier to understand what
needs to be done nutritionally. Lastly, educate them on Docusate; patient will need to be on a high fiber
diet with 1500-2000 mL fluid/day to prevent constipation.
One-day sample menu: Please refer to Appendix B for one-day sample menu.
Dietary analysis of the sample menu: Please refer to Appendix C for dietary analysis of the sample
menu.
M/E
1
2
3
4
5
6
7
8
9
10
M/E
Biochemical Data,
Medical Tests, and
Procedure Outcomes
Lab data (e.g.
electrolytes, glucose)
and tests (e.g. gastric
emptying time, resting
metabolic rate)
Anthropometric
Measurement
Outcomes
Height, weight, body
mass index (BMI),
growth pattern
indices/percentile
ranks, and weight
history
Nutrition-Focused
Physical Assessment
Outcomes
Physical appearance,
muscle and fat wasting,
swallow function,
appetite, and affect
Food/Nutrition-Related History Outcomes
NCP Terminology
Additional Notes if Applicable
Energy intake (1.1.1) Total energy
Recommended intake: 1775 kcal/day
intake
Fluid/beverage intake (1.2.1) Oral fluids Recommended intake: 2130 mL/kg
Fluid/beverage intake (1.2.1) Liquid
Recommended intake: 1 can Ensure/day
meal replacement or supplement
Food intake (1.2.2) Types of food/meals Recommended intake: puree foods with medical
nutrition supplements
Alcohol intake (1.4.1) Frequency
Recommended intake: 1 can of beer or less/day
Vitamin intake (1.6.1) C
Recommended intake: >75 mg/day
Vitamin intake (1.6.1) E
Recommended intake: 15 mg/day
Vitamin intake (1.6.1) K
Recommended intake: 90-120 mcg/day
Vitamin intake (1.6.1) Folate
Recommended intake: ~320 mg/day
Protein intake (1.5.2)
Recommended Intake : 85 g/day (1.2-1.5g/kg)
Biochemical Data, Medical Tests, and Procedure Outcomes
NCP Terminology
Additional Notes if Applicable
10
M/E
1
2
3
Anthropometric Measurement Outcomes
NCP Terminology
Additional Notes if Applicable
Body composition/growth/weight
Achieve IBW of 196 lbs
history (1.1) Weight
Body composition/growth/weight
Achieve IBW
history (1.1) Weight change
Body composition/growth/weight
Achieve desirable BMI for age of 25-30 lb/in2
history (1.1) Body mass index
M/E
1
2
3
4
5
Nutrition-Focused Physical Assessment Outcomes
NCP Terminology
Additional Notes if Applicable
Nutrition-focused physical findings
Look for appearance of muscle and weight gain
(1.1) Overall appearance: cachetic
Nutrition-focused physical findings
Aim to increase energy and lessen overall feelings of
(1.1) Overall appearance
tiredness
Nutrition-focused physical findings
Increase muscle tone by reaching healthy weight and
(1.1) Extremities, muscles and bones:
BMI of 25-30 lb/in2
loss of muscle mass in quadriceps and
gastrocnemius
Nutrition-focused physical findings
Decrease temporal wasting and increase protein
(1.1) Head and eyes: noted temporal
consumption
wasting
Nutrition-focused physical findings
Maintain normal skin temperature but reduce
(1.1) Skin: ecchymoses
presence of ecchymoses
Assessment
Chief complaint: generalized weakness; admitted to acute care for possible dehydration, wt. loss, generalized
weakness, and malnutrition
Personal Hx: 68 yo Gender: Male Medical Hx: diagnosed with squamous cell carcinoma of the tongue 5 years ago
and was treated with radiation therapy approx. 3 years ago. Hypertension, hyperlipidemia, weight loss,
peripheral vascular disease. Lipitor 80mg/d, Capoten 25mg 2x/d
2
Anthropometrics: ht: 63 (75 in), wt: 156lb (71 kg), BMI: 19.5 kg/m , IBW: 196 lb (89 kg)
Biochemical data: Sodium 150 mEq/L, MCV, Chloride 118 mEq/L, BUN 36 MG/dL, Calcium 8.4 mg/dL,
3
3
Albumin 1.8 g/dL, Prealbumin 9 g/dL, CRP 2.4 mg/dL, Cholesterol 205 mg/dL, RBC 2.4x10 /mm ,
Ketones +, Hemoglobin 8.1 d/dL.
Macronutrient intake/day: 789 kcal, 103 g CHO (52%), 68 g pro, 38 g fat (43%)
Medication Rx: 0.9 sodium chloride with potassium chloride 20 mEq 125 mL/hr, Thiamin injection 100 mg/d,
Multivitamin capsule 1 Cap/d, Docusate capsule 100 mg 2x/d, Lipitor 80 mg/d, Lopressor 5 mg/6 hrs.
Diet: prescribed a mechanical soft diet, <5% PO, states that he gets full really easily and never feels hungry.
Diagnosis
1. Inadequate oral intake R/T tongue cancer with presence of petechiae and radiation therapy treatment AEB pt
reported of being full quickly due to radiation therapy, diet recall of 789 kcal/d compared to his recommended
intake of 1775 kcal/d (25 kcal/kg), noted temporal wasting, and UBW of 220lb and CBW of 160lb (60 lbs lost
within the last 2 years).
2. Malnutrition R/T inability to manage self-care AEB diet recall of 789 kcal/d compared to the recommended
1775 kcal/d, unintended weight loss of 60 lbs, and generalized fluid accumulation (pedal edema).
Intervention
Nutrition Rx: 1775 kcal, 85 g PRO, 200-288 g CHO (45-65%), 25 g Fiber, 39-69 g Fat (20-35%), 2130 mL fluid,
Vitamin C >75 mg, Vitamin E 15 mg, Folate ~320 mg, Vitamin K 90-120 mcg.
Food and Nutrient Delivery: Modify Composition of Meals and Snacks (ND-1.2) Request for puree diet and
incorporate medical food supplements to increase total energy intake to 1775 kcal/d. Increase fluid intake to
2130 mL/d (30 mL/kg). Small meals throughout the day w/ snacks 2x/d. Asked patient what types of
food/drinks does he prefer. 2 fish oil capsule to increase LBM. May request appetite stimulant from MD if
intake does not improve.
Nutrition Education: Nutrition Relationship to Health/Disease (E-1.4) Informed patient and wife on factors
relating to malnutrition and how to prevent malnutrition by changes in diet and use of medical food
supplements. Handouts and websites offered to patient. Informed patient high fiber diet required for Docusate.
Goals:
1. Patient will increase energy intake to 1775 kcal/d with various nutrient-dense foods provided on 1-day sample
menu. Increase to 2130 kcal/d if tolerated.
2. Patient will increase fluid intake to 2130 mL/d by consuming water, milk, juice, broth, and Ensure.
References Cited in this Worksheet
Brown, J.E., Isaacs, J., Krinke, B.U., Lechtenberg, E., Murtaugh, M.A., Sharbaugh, C., Splett, P.L., &
Stang, J. (2011). Nutrition Through the Life Cycle: Nutrition and Older Adults (4th ed.). Belmont:
Wadsworth, Cengage Learning.
DeLuis, D., Izaola, O., Aller, R., Cuella, L., Terroba, M., A Randomized Clinical Trial with Oral
Immunonutrition (omega 3-enhanced formula vs. arginine-enhanced formula) in ambulatory head
and neck cancer patients. Annals of Nutrition and Metabolism. Retrieved from
http://222.andeal.org
Kano, T., Kanda, K. (2013). Development and Validation of a Chemotherapy-Induced Taste Alteration
Scale. Oncology Nursing Forum, 40(2), E79.
Mutsumi, O. (2007). Reconstruction with Rectus Abdominis Myocutaneous Flap for Total Glossectomy
with Laryngectomy. Journal Of Reconstructive Microsurgery, 23(5), 243-249.
Priya, M., Menon, R. J., Iyer, S., & Thankappan, K. (2013). OP076: Videoflouroscopic evaluation of
swallowing after glossectomy A prospective study. Oral Oncology, 49, 34.
doi:10.1016/j.oraloncology.2013.03.084
White, J., Guenter, P., Jensen, G., Malone A., & Schofield, M. (2012). Consensus Statement of the
Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition:
Characteristics Recommended for the Identification and Documentation Of Adult Malnutrition
(Undernutrition). Journal of the Academy of Nutrition and Dietetics, 112(5), 730-738.
doi:10.1016/j.jand.2012.03.012
Appendices
Appendix A. Intake analysis using Food Processor software (installed in FCS computer labs).
a. Spreadsheet
Updated 1/2015, Long Wang
b. Bar graphs
Updated 1/2015, Long Wang
Updated 1/2015, Long Wang
d. MyPlate recommendation
Appendix B. Nutrition Intervention: sample menu for one-day.
Breakfast:
2 Scrambled Eggs + tbsp Unsalted Butter + Pinch of Mrs. Dash Seasoning
6 oz Pancake Slurry
8 oz Oatmeal + Small Pureed Banana
8 oz Coffee + 1 Half and Half
AM Snack:
Chocolate Strawberry Milkshake (4 oz Chocolate Ensure plus + 2 oz Strawberries)
8 oz Water
Lunch:
4 oz Pureed Roasted Chicken
4 oz Pureed Spinach
4 oz Pureed Sweet Potatoes
2 tsp Unsalted Butter
6 oz Pureed Split Pea Soup
4 oz Orange Juice (to enhance protein absorption)
PM Snack:
Fruit and Cottage Cheese Plate (4 oz Cottage Cheese + 4 oz Pureed Fruit Cocktail)
4 oz Coconut Water
4 oz Water
Dinner:
4 oz Pureed Enriched Pasta
2 Pureed Meatballs
4 oz Marinara Sauce
8 oz Pureed Cauliflower, Broccoli, Zucchini Blend
2 tsp Unsalted Butter
8 oz Water ( squeezed lemon + 1 mint leaf)
Dessert:
2 oz Vanilla Greek Yogurt + 1 tbsp Crushed Walnuts + tsp Cinnamon
4 oz Water
4 oz Butter Pecan Ensure Plus
Appendix C. Analysis of the sample menu using Food Processor software.
e. Spreadsheet
Updated 1/2015, Long Wang
f.
Bar graphs
Updated 1/2015, Long Wang
Updated 1/2015, Long Wang
h. MyPlate recommendation