case study 1 (q3)

CASE STUDY 1:

Group members:Nor Faezah Baba 0914092Nor Zawani Nor Adnan 0917466Nur Syazana Mohd Zahir 0918594Siti Rokiah Mohamad Hadzri 0911724Nur Syahidatul Aswani Mohd Rozin 0913604

QUESTION 3

Mr TEC, 62 years old Chinese man was admitted to

oncology ward due to metastatic adenocarcinoma neck

cancer. He was on radiotherapy. Initially, patient was able

to eat orally. However, recently he experienced poor oral

intake due to dysphagia. Therefore, he was referred to

dietitian for nutritional support. Patient’s height is 172 cm

and his weight before admission was 68 kg, but since

admission, he had lost 5 kg due to poor appetite and poor

oral intake. Plan for this patient’s EN regime.

A) INTRODUCTION

Terms Description

Metastasis Adenocarcinoma neck cancer

Adenocarcinoma neck cancer usually begins in the squamous cells that line the moist, mucosal surfaces inside the head and neck. These squamous cell cancers are often referred to as squamous cell carcinomas of the head and neck Head and neck cancers can also begin in the salivary glands, but salivary gland cancers are relatively uncommon

- The most important risk factors for head and neck cancers are alcohol and tobacco use. These risk factors are particularly important for cancers of the oral cavity, oropharynx, hypopharynx, and larynx. People who use both tobacco and alcohol are at greater risk of developing these cancers than people who use either tobacco or alcohol alone.

dysphagia Condition in which swallowing is difficult or painful

B) NUTRITIONAL STATUS ASSESMENT

1. SUBJECTIVE DATANAME MR TEC

AGE 62 YEARS OLD

SEX MALE

RACE CHINESE

2. ANTHROPOMETRY DATAHeight 172 cm

Weight 63 kg

BMI 21.3 kg/m (normal)


3. BIOCHEMICAL DATAParameter Data Reference

RangeIndication Explaination

Sodium 125 mmol/L 135 - 145 mmol/L

Low Indication of overhydration

Potassium 3.6 mmol/L 3.5 – 5.1 mmol/L

Normal -

Urea 2.7 mmol/L 2.9 - 7.9 mmol/L

Low Indication of malnourish. Also due to low total protein

Creatinine 77 mmol/L 35 - 132 mmol/L Normal -Albumin 28 g/L 35- 50 g/L Low Indication of malnourish

Total Protein 62 g/L 64 - 83 g/L Low Indication of malnourish

Bilirubin (Total)

11 μmol/L 5 – 29 μmol/L Normal -

ALT 20 U/L 8 - 45 U/L Normal -ALP 74 U/L 30 – 130 U/L Normal -


4. CLINICAL DATAMetastatic adenocarcinoma neck cancer

Dysphagia

Loss of appetite

Poor oral intake

Loss 5 kg after admission•Percentage of weight loss

= 68- (68-5) x 100 = 7% 68


5. EXTRA INFO

Was on radiotherapy


C) DIAGNOSIS

PES statement

Poor oral intake related to dysphagia as evidence by loss of 5 kg of body weight

Objectives Principles1. To provide adequate calorie

intake to prevent further weight loss

•Introduce suitable enteral feeding 6 times per day

2. To provide doses of nutrients compatible with existing metabolism.

•CHO = 50 - 60%•Prot = 15 - 20 % (1.5 – 2.0g/kg/day)> To ensure adequate protein to avoid malnutrition•Fat = ≤ 30%

3. To avoid or manage complications related to the technique of nutritional delivery.

•Increase the amount of formula regime gradually.•Introduce modular products one by one.

4. To attain and maintain optimal biochemical status/value

• ensure optimum value of biochemical status and prevent electrolyte imbalance

D) INTERVENTION

D) INTERVENTION

1. Calculation of Energy Requirements

BMI= 21.3 kg/m2 Weight = 63kg Age= 62 years old 1. Quick method

ER = 63 kg x 35 kcal/kg* = 2205 kcal/day

* = we use 35kcal/kg because he is slightly hypermetabolic

D) INTERVENTION1. Calculation of Energy Requirements

BMI= 21.3 kg/m2 Weight = 63kg Age= 62 years old

2. Harris – Benedict calculations BEE = 66.47 + 13.75(W) + 5.0(H) – 6.76(A) = 66.47 + 13.75(63) + 5.0(172) – 6.76(62) = 1373.6 kcal/day TEE = BEE X AF (normal) X IF (Cancer px)

=1373.6 x 1.3 X 1.5=2678.52 kcal

AVERAGE CALORIE INTAKE = 2678.52+ 2205 2 = 2441.76 kcal/day ~ 2442 kcal/day

D) INTERVENTION

2. Calculation requirement ofPRO CHO FAT

1.5 g/kg/day x 63 kg = 94.5 g/day94.5 d/day x 4 kcal =378 kcal 378 x 100 kcal = 15.48 % 2442≈ 15.5So, we choose 16 % of protein/day

57 x 2442 kcal = 1391.9 kcal100 4

= 348 g/day

27 x 2442 kcal = 659.3 kcal 100 9

= 73.3 g/day

D) INTERVENTION2. Recommendation

Specialize formula

rich in EPA and high level of protein and calories

Therapeutic nutrition for people experiencing unwanted weight loss

Clinically shown to promote weight gain, increase lean body mass and strength, enhance physical activity.

Improve quality life of people with cancer

Nutritional information (per scoop)

Recommendation

Energy 33 kcal 2442/ 33 kcal = 74 scoops

CHO 5.4 g 74 scoops x 5.4 g = 399.9 g

Protein 1.8 g 74 scoops x 1.8g = 133.2 g

Fat 0.7 g 74 scoops x 0.7 g= 51.8 g

Dilution 1 scoop : 21 ml of water

D) INTERVENTION

Step Dilution MODULAR PRODUCT

STEP 1 2 scoops + 40 ml of water -

STEP 2 4 scoops + 90 ml of water -

STEP 3 8 scoops + 170 ml of water Carborie *

STEP 4 12 scoops + 260 ml of water Carborie + myotein**

D) INTERVENTION

* glucose polymer for person with increase energy need or unable to achieve sufficient energy** for people with increase protein needs or patient that cannot achieve sufficient protein

Calories Protein CHO FAT

= 2 scp X 33 kcal = 66 kcal x 6 F= 396 kcal

= 2 scp x 1.8 g = 3.6 g x 6 F= 21.6 g

=2 scp x 5.4 g= 10.8 g x 6 F= 64.8 g

= 2scp x 0.7 g= 1.4 g x 6 F= 8.4 g

If pt can tolerate 2 feeding, go to step 2. Before and after feeding flush with 30ml of water

D) INTERVENTION

STEP 1 : 2 scoops + 40 ml of water ( 4 hrly/6 x/

day)

D) INTERVENTION


day)Calories Protein CHO FAT


= 4 scp x 1.8 g = 7.2 g x 6 F= 43.2 g

=4 scp x 5.4 g= 21.6 g x 6 F= 129.6 g

= 4scp x 0.7 g= 2.8 g x 6 F= 16.8 g


STEP 3 : 8 scoops + 170 ml of water ( 4 hrly/6 x/ day)




= 8 scp x 1.8 g = 14.4 g x 6 F

= 86.4 g

=8 scp x 5.4 g= 43.2 g x 6 F

= 259.2 g

= 8scp x 0.7 g= 5.6 g x 6 F

= 33.6 g

Introduce carborie

+ 3 scoops carborie + 24 kcal - +5.7 g CHO -

TOTAL 1608 kcal 86.4 g 264.9 g 33.6 g

D) INTERVENTION

1 scoop of Carborie : = 8 kcal/ ml=1.9 g of CHO


= 12 scp X 33 kcal = 396 kcal x 6 F

= 2376 kcal

= 12 scp x 1.8 g = 21.6 g x 6 F

= 129.6 g

=12 scp x 5.4 g= 64.8 g x 6 F

= 388.8 g

= 12 scp x 0.7 g= 8.4 g x 6 F

= 50.4 g

Introduce1.+ 4 scoops carborie

2. +2 tbsp myotein

+ 32 kcal

+ 38.2 kcal

-

6.0 g

+7.6 CHO

-

-

-

TOTAL 2376 + 32+ 38.2 =2446.2 kcal

129.6 + 3.0= 132.6 g

388.8 + 7.6 = 396.4 g = 50.4 g


day

1tbsp of MYOTEIN : = 19.1 kcal/ml=3g of Protein

GOAL 2442 kcal 133.2 g 399.9 g 51.8 g

ImplementationFlush 20 – 30 ml of water before and after feeding.

Confirm that the tip of the feeding tube is properly positioned.

Elevate the head of bed 30 - 45° during feedings and 30 – 60 mins after bolus feedings.

6 times daily, for every 4 hours.

D) INTERVENTION

E) ADDITIONAL INFO

case study 1 (q3)

Health & Medicine

gkgday x

gday57 x

dday x

bee x af normal x

neck cancers

scoops cho

neck head

d intervention2