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case study 1 (Q3)

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case study 1 (Q3)

case study 1 (Q3)


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  • 1. CASE STUDY 1: Group members: Nor Faezah Baba 0914092 Nor Zawani Nor Adnan 0917466 Nur Syazana Mohd Zahir 0918594 Siti Rokiah Mohamad Hadzri 0911724 Nur Syahidatul Aswani Mohd Rozin 0913604
  • 2. QUESTION 3Mr TEC, 62 years old Chinese man was admitted to oncologyward 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 fornutritional support. Patient’s height is 172 cm and his weightbefore admission was 68 kg, but since admission, he had lost5 kg due to poor appetite and poor oral intake. Plan for this patient’s EN regime.
  • 3. A) INTRODUCTIONTerms DescriptionMetastasis Adenocarcinoma neck cancer usually begins in the squamousAdenocarcinoma cells that line the moist, mucosal surfaces inside the head andneck cancer 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
  • 4. B) NUTRITIONAL STATUS ASSESMENT 1. SUBJECTIVE DATA NAME MR TEC AGE 62 YEARS OLD SEX MALE RACE CHINESE
  • 5. B) NUTRITIONAL STATUS ASSESMENT2. ANTHROPOMETRY DATAHeight 172 cmWeight 63 kg BMI 21.3 kg/m (normal)
  • 6. B) NUTRITIONAL STATUS ASSESMENT 3. BIOCHEMICAL DATA Parameter Data Reference Indication Explaination RangeSodium 125 mmol/L 135 - 145 Low Indication of overhydration mmol/LPotassium 3.6 mmol/L 3.5 – 5.1 Normal - mmol/LUrea 2.7 mmol/L 2.9 - 7.9 Low Indication of malnourish. Also due to low mmol/L total proteinCreatinine 77 mmol/L 35 - 132 mmol/L Normal -Albumin 28 g/L 35- 50 g/L Low Indication of malnourishTotal Protein 62 g/L 64 - 83 g/L Low Indication of malnourishBilirubin 11 μmol/L 5 – 29 μmol/L Normal -(Total)ALT 20 U/L 8 - 45 U/L Normal -ALP 74 U/L 30 – 130 U/L Normal -
  • 7. B) NUTRITIONAL STATUS ASSESMENT 4. CLINICAL DATA Metastatic 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
  • 8. B) NUTRITIONAL STATUS ASSESMENT 5. EXTRA INFO Was on radiotherapy
  • 9. C) DIAGNOSIS PES statementPoor oral intake related to dysphagia asevidence by loss of 5 kg of body weight
  • 10. D) INTERVENTION Objectives Principles1. To provide adequate calorie •Introduce suitable enteral feeding 6 times per day intake to prevent further weight loss2. To provide doses of nutrients •CHO = 50 - 60% compatible with existing •Prot = 15 - 20 % (1.5 – 2.0g/kg/day) metabolism. > To ensure adequate protein to avoid malnutrition •Fat = ≤ 30%3. To avoid or manage •Increase the amount of formula regime gradually. complications related to the •Introduce modular products one by one. technique of nutritional delivery.4. To attain and maintain • ensure optimum value of biochemical status and optimal biochemical prevent electrolyte imbalance status/value
  • 11. D) INTERVENTION 1. Calculation of Energy RequirementsBMI= 21.3 kg/m2 Weight = 63kg Age= 62 years old1. Quick method ER = 63 kg x 35 kcal/kg* = 2205 kcal/day* = we use 35kcal/kg because he is slightly hypermetabolic
  • 12. D) INTERVENTION 1. Calculation of Energy RequirementsBMI= 21.3 kg/m2 Weight = 63kg Age= 62 years old2. 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
  • 13. D) INTERVENTION 2. Calculation requirement of PRO CHO FAT1.5 g/kg/day x 63 kg =94.5 g/day 57 x 2442 kcal = 1391.9 kcal 27 x 2442 kcal = 659.3 kcal94.5 d/day x 4 kcal =378 100 4 100 9kcal 378 x 100 kcal = 15.48 % = 348 g/day = 73.3 g/day 2442≈ 15.5So, we choose 16 % ofprotein/day
  • 14. D) INTERVENTION 2. 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
  • 15. D) INTERVENTION Nutritional information Recommendation (per scoop) 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 gDilution 1 scoop : 21 ml of water
  • 16. 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*** 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
  • 17. D) INTERVENTION STEP 1 : 2 scoops + 40 ml of water ( 4 hrly/6 x/ day)Calories Protein CHO FAT= 2 scp X 33 kcal = 2 scp x 1.8 g =2 scp x 5.4 g = 2scp x 0.7 g= 66 kcal x 6 F = 3.6 g x 6 F = 10.8 g x 6 F = 1.4 g x 6 F= 396 kcal = 21.6 g = 64.8 g = 8.4 g If pt can tolerate 2 feeding, go to step 2. Before and after feeding flush with 30ml of water
  • 18. D) INTERVENTION STEP 2 : 4 scoops + 90 ml of water ( 4 hrly/6 x/ day)Calories Protein CHO FAT= 4 scp X 33 kcal = 4 scp x 1.8 g =4 scp x 5.4 g = 4scp x 0.7 g= 132 kcal x 6 F = 7.2 g x 6 F = 21.6 g x 6 F = 2.8 g x 6 F= 792 kcal = 43.2 g = 129.6 g = 16.8 g If pt can tolerate 2 feeding, go to step 3. Before and after feeding flush with 30ml of water
  • 19. D) INTERVENTION STEP 3 : 8 scoops + 170 ml of water ( 4 hrly/6 x/ day) Calories Protein CHO FAT = 8 scp X 33 kcal = 8 scp x 1.8 g =8 scp x 5.4 g = 8scp x 0.7 g = 264 kcal x 6 F = 14.4 g x 6 F = 43.2 g x 6 F = 5.6 g x 6 F = 1584 kcal = 86.4 g = 259.2 g = 33.6 gIntroduce carborie + 3 scoops + 24 kcal - +5.7 g CHO - carborie TOTAL 1608 kcal 86.4 g 264.9 g 33.6 g If pt can tolerate 2 feeding, go to step 4. Before and after feeding flush with 30ml of water
  • 20. STEP 4 : 12 scoops + 260 ml of water ( 4 hrly/6 x/ day Calories Protein CHO FAT = 12 scp X 33 kcal = 12 scp x 1.8 g =12 scp x 5.4 g = 12 scp x 0.7 g = 396 kcal x 6 F = 21.6 g x 6 F = 64.8 g x 6 F = 8.4 g x 6 F = 2376 kcal = 129.6 g = 388.8 g = 50.4 gIntroduce1.+ 4 scoops carborie + 32 kcal - +7.6 CHO -2. +2 tbsp myotein + 38.2 kcal 6.0 g - -TOTAL 2376 + 32+ 38.2 129.6 + 3.0 388.8 + 7.6 =2446.2 kcal = 132.6 g = 396.4 g = 50.4 gGOAL 2442 kcal 133.2 g 399.9 g 51.8 g
  • 21. D) INTERVENTION ImplementationFlush 20 – 30 ml of water before and after feeding.Confirm that the tip of the feeding tube is properlypositioned.Elevate the head of bed 30 - 45° during feedings and 30 – 60mins after bolus feedings.6 times daily, for every 4 hours.
  • 22. E) ADDITIONAL INFO