Ms. Richart presents to the ED for planned admission for tracheostomy and G-tube placement before CRT has given newly dx SCC of hypopharynx (dx 1/2021). Endorses hunger and appetite. However, c/o severe odynophagia impacting her PO intake, mainly eating pureed/soft food items and liquids. S/p (tracheostomy tube placement yesterday. Plan for G-tube placement today. Pt currently NPO pending SLP evaluation of the patient's swallowing function. Afebrile and HDS on admission. BP 125/82. Will admit to SICU. RD consulted for TF recommendations.  

 

Case Study 5 

 

Name: Ms. Richart

Age: 60 y/o

Sex: Female

 

PMHx: HTN, HLD, newly diagnosed SCC of the hypopharynx (dx 1/2021)

 

RFA: Planned admission for tracheostomy and G-tube placement before chemoradiation therapy (CRT) 

 

DOA:4/14/2021 

 

Tobacco use: Quit earlier this year, previously 30 packs per year 

Living situation: Lives alone in one story home 

Occupation: Retired 

Marital status: Single, no children 

Family history: Sister has breast cancer 

  

ANTHROPOMETRIC DATA:

 

Height: 68" 

Most Recent: 160.1 (72.6kg)

BMI: 

72.6/(1.72)^2 

72.6 /2.95 = 24.3  BMI

 

Weight History x 1 year: 

4/14/2021 160.1# 

3/9/2021 168.6# 

2/8/2021 170.2# 

1/4/2021 175.5# 

12/22/2020 181.2# 

12/6/2020 180.6# 

10/15/2020 180.5# 

10/1/2020 181.2# 

9/18/2020 180.1# 

6/19/2020 184.6# 

4/4/2020 183.1# 

 

Past Year 

Lost 23 pounds 

Past six months 

181.2 -160.1 = 21.1 

21.1 /181.2 = 11.6%

 

Six months > 10% weight  loss 

 

The patient's BMI is low for their age.

 

BIOCHEMICAL DATA:

 

Labs (drawn on admission): 

Phos: 2.1  mg/dL (L)  

K: 3.7 mmol/L  

Na: 138 mmol/L  

Mg: 2.0 mg/dL  

Caclum  7.8 mg/dL (L)

Albumin: 3.2 g/dL (L)   

 

 

• Phosphorates are low. We want to monitor to prevent hypophosphatemia when phosphorate levels are in the < 2.5mg/dL.
• Sodium levels tell you about the hydration status or if edema is present, so we want to continue to monitor these levels for the patient. 
• Magnesium needs to help absorb calcium.
• 3.7 mmol/L potassium is in the normal range. However, we do not want it to not be higher because of a history of hypertension and how it affects the patient's blood pressure. 
• Low Calcium and Albumin 
• Low levels of albumin may be low due to cancer found from the SCC of the hypopharynx 

 7.8mg/dL + 0.8 (4-3.2g/dL)

 7.8mg/dL + 0.8(0.8 g/dL)

  7.8mg/dL + 0.64 = 8.44 mg/dL corrected calcium

 

NUTRITION-FOCUSED PHYSICAL EXAM

 

Ms. Richart's skin assessment shows mild LBM wasted in the temples but no subcutaneous fat wasting. No open wounds.

 

MALNUTRITION SCREENING TOOL

 

Lost weight recently without trying: Yes, 11-15kg (3 points)  

Eating poorly due to decreased appetite: No (0 points) 

A total score of 3. 

 

According to the Malnutrition Screening Tool, a score of 2 or more puts the patient at risk of malnutrition (Charney et al., 2022). In addition, according to the Malnutrition in the context of Chronic Illness as per Academy/ASPEN, clinical characistsitics of more than 10% of interpretation of weight loss over the past six months put our client in the severely malnourished category.

 

BRADEN AND SKIN ASSESSMENT:  Score at 19, nutrition subscore 2 

 

  

FOOD AND NUTRITION HISTORY

 

24-hour recall: 

B: ½ cup grits, 1 Greek yogurt cup, ½ cup apple juice 

L: 1 vanilla pudding cup, one bowl of pureed chicken noodle soup, ¼ cup cottage cheese 

D: 1 applesauce cup, ½ cup mashed potatoes w/ gravy, ½ cup vanilla ice cream  

Snacks: Drank 1 Ensure Plus supplement after dinner 

Beverages: Drank ~4 cups of water yesterday.  

 

This 24-hour recall no longer applies to the patient; they are NPO due to swallowing difficulties. The patient has no loss of appetite at this time and has a purred aid diet. She must eat foods purred according to IDDSI guidelines. The patient will return to a standardized purred plate diet once SLP sees the patient. 

GASTROINTESTINAL SYMPTOMS: No n/v/c/d

 

CHEWING/SWALLOWING: pending SLP evaluation, possibly level 4  due to the patient's swallowing function. The patient is having odynophagia. 

 

NUTRITIONALLY PERTINENT MEDICATIONS AND SUPPLEMENTS:

 

Lisinopril 60 mg PO daily

 

Estimated Nutrition Needs

 

RMR= (10 x weight in kg) + (6.25 x height in cm) - (5 x age in years) -161

 

RMR = (10 x 72.6 kg) + (6.25 x 172.72) - (5 x 60) -161

RMR= 726 +1,079.5 -300-161

RMR= 1,344.5 x 1.0-1.39 (ADLs sedentary patient). However, patients' needs may be higher. 

        = 1,344 kcal-1868.9 kcal

1868.9 kcal + 1344 kcal = 3212.9 kcal / 2 = 1606.45 kcal 

 

We want to choose the middle range due to the patient's sedentary lifestyle. 

 

72.6 kg  x 1.2-1.5kg = 87.12- 108.9 protein needs.  

 

Ms. Richart's Protein needs to be increased to  1.5g/kg daily. The choice would be 1.5  

Because 11%  is a lot of weight in six months that has been lost, he needs a higher 

intake of protein needs.

 

Fluids

 

1mL/kcal= ranging from 1,344- 1868.9 mL/day

 

Continuous TF rate :

 Total volume of TF:  estimated calorie needs = 1868.9 kcal / 2.0 =  of 1.5 Isosource

Rate per hour of TF:   1,245.9 mL / 24 = 51.9~ 50 

50 x 24= 1,200 of Isosource

1. Calories : Isosource 1.5 50 @mL/hr = 1,200 x 1.5 calories/mL= 1,800
2. Protein: 1.8 L x 68 g = 122.4 
3. Free water: 1.8 Liters x 764 mL = 1,375.2 free water.
4. Additional free water: total needed fluid = 1,800-1,375.2=424.8mL

424.8mL/4= 106.2 mL

 

NUTRITION DIAGNOSIS:

PES Statement:

• Problem: Inadequate intake as related to 
• Etiology: New diagnosis of the hypopharynx and severe odynophagia as evidenced by:
• Symptoms: Reported intake of mainly pureed/soft foot items and liquids due to swallowing difficulties and loss of 11.6% of body weight in the past six months.

 

 

 

NUTRITION INTERVENTION:

Nutrition Prescription: 

 

Vitamin/mineral supplements

Lifestyle modifications:

Collaboration: SLP

 

 RD consulted for TF recommendations.

 

 

MONITORING AND EVALUATION:

 

Will monitor 

SMART GOALS

Will monitor 

SMART GOALS 

 

 

Calories:

Protein:

Fat: 

 

Supplemental Questions (assume the patient weighs 146.3# for the following questions): 

1. Pt tolerates continuous feeds well. On day 3 of admission, pt is evaluated by SLP and cleared for dysphagia pureed diet w/ thin liquids. Ms. Richart still has inadequate oral intake and only meets ~25% of her nutrient needs PO. Please provide appropriate, updated TF recommendations for the remainder of her nutrient needs. Ms. Richart prefers to receive bolus feeds now as she wants to avoid being connected to a pump. Include goal volume (# of cartons/day), formula name, the timing of feeds, additional FWF needed, and how many kcal/pro/water this TF regimen will provide her. Please show your work. (1.5 points)

 

 

1. On day 6 of admission, pt c/o abdominal pain + constipation. CT scan reveals c/f small bowel obstruction—TF d/c and pt NPO. A PICC line was placed, and RD consulted for TPN recs. Please calculate an appropriate TPN regimen. Assume estimated needs 25-30 kcal/kg, 1.2-1.5 g protein/kg, and 30-40 mL fluid/kg. Please show your work. (1.5 points)

 

Please provide your recommendations for amounts of: 

• Dextrose (in grams)  - 0.3 points
• Amino Acids (in grams) - 0.3 points
• Lipids (in grams) - 0.3 points
• Total fluid (in mL) - 0.3 points
• Provide the calculated GIR for the amount of dextrose you recommended - 0.3 points.