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    Clinical Case Study

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    Aubrey Stueckler
    Pt with tongue carcinoma, partial glossectomy, partial neck dissection with the need for long-term TF regime during radiation therapy.

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    Clinical Case Study

    Uploaded by

    Aubrey Stueckler
    172 views18 pages
    Pt with tongue carcinoma, partial glossectomy, partial neck dissection with the need for long-term TF regime during radiation therapy.

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    © © All Rights Reserved

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    Pt with tongue carcinoma, partial glossectomy, partial neck dissection with the need for long-term TF regime during radiation therapy.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    172 views18 pages

    Clinical Case Study

    Uploaded by

    Aubrey Stueckler
    Pt with tongue carcinoma, partial glossectomy, partial neck dissection with the need for long-term TF regime during radiation therapy.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 18

    Nutrition Support

    & metastatic tongue carcinoma

    Clinical Case Study


    Aubrey Stueckler
    KSC Dietetic Intern
    Emerson Hospital
    Concord, MA

    Emerson Hospital is a regional Known for:


    medical center that provides Clough Birthing Center
    advanced medical services. Urgent Care Centers
    Services 300,000 people in Breast Health Center
    25 towns. Bone & Joint
    179 bed hospital Center for Weight Loss
    300 primary care doctors Mass General Cancer Center
    and specialists & Naka Infusion Center
    Emerson Hospital
    Clinical Dietitians

    2 Full-time Part-time Outpatient RD


    CCU, N5 Behavioral Health, WH4 Mostly cancer patients and diabetes.
    including pediatrics, 1 day at CNM
    outpatient. Covers any floor needed.
    N6 Med-Surg & Telemetry, WH5 Kitchen and Service Response Center
    Weekly nutrition classes to Management
    behavioral health unit Weight Loss
    Outpatient Nutrition for 2 outpatient bariatric RDs off-site. Come
    Recovery. to the hospital once a week post-
    Manage Service Response Center surgery/consult
    1 Part-time
    Maternity unit, TCU
    Oral Cancer
    Pathophysiology:

    Nelms, 707
    Oral Cancer, cont.
    Causes: Radiation from other cancer/treatments, tobacco, chronic alcohol use, or a combination
    of both.
    Notes from Lahey Hospital- squamous cell carcinoma of the tongue, metastasized to
    patients neck.
    Diagnosis & Treatment: Patients cancer diagnosis was confirmed by histological procedures,
    including biopsy of lesion on the tongue. Research indicates mets from oral cancer most often
    travel through neck lymph nodes and then to other major organs such as the lungs.
    Treatment options: combination of surgery and radiation therapy, surgery includes
    removal of neck lymph node, removal of lesions, removal or part of neck.
    Other oral cancers include radiation/chemotherapy.
    Nutrition support via TF or CPN.
    Relevant Labs & Medications
    Of note:
    Calcium levels
    Prealbumin
    Electrolyte imbalances
    Complete blood cell count

    Medications focus on pain management and side effects from radiation therapy.
    Side effects: dry mouth, tooth decay, jaw bone damage, mouth sores, bleeding gums, jaw
    stiffness, fatigue, skin reactions, difficulty swallowing/chewing.

    Patient only had aspirin, protonix, and zofran relevant to his cancer diagnosis/treatment.
    Medical Nutrition Therapy
    Primary goal: Prevent malnutrition
    Higher nutrient needs required
    Chronic TF is used frequently in head/neck cancers if patient is experiencing difficulty
    swallowing, chewing, pain and in order to maintain their weight status.
    Types of TFs and administration/access
    NG tube: enter in the nose and feed into stomach.
    G-tube: very common; used for long-term nutrition support
    ND tube: enter the nose and down to duodenum
    NJ: enter the nose and down to jejenum
    GJ: enter the stomach directly; a second tube into the small intestine for direct feeds when
    gastric feeds are not tolerated
    J-tube: placed directly into small intestine; not common; slow feedings over 18-24 hrs.
    Case Study:
    85 yo male (D.H.)
    Height: 58
    UBW: 150#
    Weight at Admission: 146# (down 4# from UBW in 1 month = 2.6% unintended wt loss)
    Reason for visit: Anemia, FTT, ?GI bleed
    PMH: CKD, CAD, HEARING LOSS, HIATAL HERNIA, PAROXYSMAL AFIB, CABG
    Recent procedure at Lahey (June 2017): Left partial glossectomy with left neck dissection d/t
    stage III carcinoma of the tongue.
    Previous Nutrition Intervention: Pt has had coumadin education in past. Nutrition knowledge is
    limited. Will receive outpatient nutrition appts before radiation tx starts.
    PTA: 8/1/17:
    June 2017:
    Pt was diagnosed with stage III carcinoma of the tongue. Pt had swallow evaluation
    Pt has hx of smoking and drinking 6 beers/day Moist, ground texture with thin
    Had a procedure which included a left partial glossectomy with liquids; straws allowed.
    left neck dissection. Medications in puree
    Plan to start radiation in late August 2017. Nursing Assessment/Notes
    Pt lives alone but independent
    at baseline

    7/31/17: Tolerating soft diet but only 5-


    10% PO intake

    Pt admitted for Anemia, FTT, and ?GI Bleed


    Nutrition Referral on admittance for lack of appetite.
    Speech was referred for a swallow evaluation.
    8/2/17: Initial Nutrition Assessment
    Anthropometrics
    Confirmed Ht/Wt
    Endoscopy for ?GI Bleed
    Revealed Esophageal Ulcer UBW 150# (current wt at 145#)
    NPO for procedure Unintentional wt loss d/t 2 months
    UTI + poor appetite.
    IV ABX Reports pain in throat
    Lactinex No chewing/swallowing issues
    LBM 8/1 with blood present No appetite here, usually good at home.
    Bowels: Diarrhea, black stools x2 days,
    Abdominal pain
    Biomedical
    Prealbumin: 13 WNL
    Na: WNL
    Albumin: 2.9 Low
    Calcium: WNL
    Diagnosis: Intervention:
    PES Statements: Meals & Snacks: Regular diet; textures
    1. Altered GI function r/t ?GI Bleed AEB consistent w/ SLP recs; assistance with
    abdominal pain, diarrhea, black stools ordering meals.
    x2 days, + Guaiac BM 8/1. Nutrition-related med mgmt: RX list includes
    2. Inadequate oral intake r/t left partial coumadin d/t paroxysmal AFIB. Continue
    glossectomy with left neck dissection Lactinex for UTI.
    AEB nursing reports 5-10% PO intake of Medical Food Supplements: Will send Boost
    soft texture diet, SLP recommending compact BID at 10am & 2pm.
    moist ground diet, and pt reporting low Vit/min supplement: Rec MVI w/min d/t
    appetite. Malnutrition risk.
    3. Unintended weight loss r/t tongue
    carcinoma AEB pt reports 2 months of
    poor appetite with 4lb wt loss.
    Monitor:
    Biochemical/medical tests: BMP, Mg, Phos, Prealb
    Body Composition: Weight changes
    Energy Intake: %PO intake, MFS intake, Diet tolerance
    GI Profile: BM function
    Physical findings r/t nutrition: Swallowing/chewing issues
    8/3/17:
    New PES Statement: Moderate protein/calorie malnutrition r/t tongue carcinoma AEB pt reports 2
    months of poor appetite with 4lb weight loss, and need for G-tube placement.
    Revised old PES statement: Inadequate oral intake r/t left partial glossectomy with left neck
    dissection AEB pt reports pain when swallowing, pt requiring TF with plans for radiation therapy,
    and decreased PO intake x1 month.
    Recommended:
    Isosource 1.5 by Gravity Feeds/IV pole in order to maintain pts quality of life at home and during
    radiation therapy.
    At goal, patient will receive two cans 3x/day, providing 2250 kcal (34kcal/kg) and 102g protein
    (1.5 g/kg).
    Pt will require 120cc free water flush before and after each feeding and 300cc bolus feeding
    during day to meet fluid needs. (total of 2178cc water = 33cc/kg)
    8/7/17:
    Nutrition Services consulted for Re-adjustment of TF Regime, per MD. MD asking for continuous
    feedings.
    Nursing reports pt refusing TF over weekend because he thinks the day 1 (8/4) of TF gave him
    diarrhea, bloating, and abdominal pain.
    Pt had ~25% PO intake. He had half eaten cereal/milk on table; refused MFS. Pt reports no diarrhea to
    nutrition services, no abdominal pain.
    Goal:
    Initiate continuous feeding at slow rate over longer period of time for tolerance.
    Pt to tolerate TF pump and then transition to overnight feedings as outpatient.
    Recommended:
    Isosource 1.5 continuous feed at goal rate of 63ml/hr via G-tube.
    Begin at 23mL/hr, increase by 20mL/hr every 8 hours, if tolerated.
    Water flush 170mL every 4 hours
    Evaluation:
    Biochemical/medical tests:
    All labs remained WNL and at patients baseline.
    Calcium did decrease; however, corrected calcium was WNL.
    Body Composition:
    Patients wt remained stable; he lost 2# in 1 week but is now tolerating some PO intake and TF regime.
    Energy Intake: %PO intake, MFS intake, Diet tolerance
    Pt refused all MFS; %PO intake increased from 5-10% to 25%. Tolerating TF regime.
    GI Profile:
    Pt with soft BM 8/6 - no blood present
    Physical findings r/t nutrition:
    Malnutrition status will be followed by Cancer Center and outpatient RD.
    Chewing/swallowing function will be followed by Cancer Center and speech therapy.
    Thanks!
    Any questions?
    Credits

    Beaver ME, Matheny KE, Roberts DB, Myers JN. Predictors of weight loss during radiation
    therapy.Otolaryngol Head Neck Surg. 2001;125(6):645-648. doi:10.1067/mhn.2001.120428.
    Lesser M, Sappah L. Head and Neck. Nutrition Care Manual.
    https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&ncm_toc_id=145170#.
    Published March 2016. Accessed September 12, 2017.
    Nelms M, Sucher KP, Lacey K, Roth SL. Nutrition Therapy & Pathophysiology. 2nd ed. Belmont, CA:
    Wadsworth; 2011.
    Overgaard J, Hansen HS, Specht L, et al. Five compared with six fractions per week of conventional
    radiotherapy of squamous-cell carcinoma of head and neck: DAHANCA 6 and 7 randomised controlled
    trial. Lancet. 2003;362(9395):1588. https://www.ncbi.nlm.nih.gov/pubmed/14511925. Accessed
    September 12, 2017.

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