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Clinical Case Study: Gastrointestinal Cancer and Severe MalnutritionMaggie Chen, dietetic intern, CSU San Bernardino ISPPSouthern California Hospital at Culver CityDate of presentation: April 17, 2019Overview of Disease State: Since the gastrointestinal (GI) system involves heavily with the digestion and absorption of nutrients, any disease related to the GI tract can significantly impact the nutritional status. Because GI tract’s significant importance on nutrition status, medical nutrition therapy intervention (MNT) always prioritizes oral feeding and tube feeding to preserve the structural and functional integrity of the GI tract. MNT only recommends total or peripheral parenteral nutrition when the gut is no longer functional or needs bowel rest temporally. The GI system is divided into the upper GI tract and the lower GI tract. The upper GI tract consists of mouth, pharynx, esophagus, and stomach, and the lower GI tract consists of the small and large intestine. When food is consumed, the food primarily stores in the body of the stomach for mechanical digestion, followed by mixing with the gastric juices in the antrum, and finally empty into the small intestine for further digestion. The mechanical and chemical digestion process in the stomach helps break down the complex macronutrients into smaller particles, so the small intestine can better digest and absorb the nutrients. Without food being first digested in the stomach before entering the small intestine, it can lead to dumping syndrome and malabsorption. Hence, the stomach is an important key organ for the healthy digestive process even though 98% of all digestion and absorption occurs in the lower GI tract. (Nelms 2014 pg 342-347)Therefore, gastric cancer can lead to the development of malnutrition since the tumor affects the digestive process. The abnormal and malignant growth of cell mass in the stomach can also cause alterations in macronutrient metabolism, which can stimulate more tumor growth and metastasis. According to “Gastric Cancer: Epidemiology, Prevention, Classification, and Treatment” by Sitarz Robert, gastric cancer is triggered by a combination of environmental factors and accumulation of specific genetic alterations; Poor hygiene, spoiled food, poor food conservation, and Helicobacter pylori are all correlated with gastric cancer development. Therefore, better hygiene, increase intake of fresh produce/food, improved food conservation, eradicating Helicobacter pylori, and early screening are good prevention strategies. Prevention is very important because there is no cure for gastric cancer once it is developed. The current medical interventions for gastric cancer patients are usually surgical resection (partial or total gastrectomy) and chemotherapy (Sitarz 2018).One of the reasons why gastric cancer can be deadly because the disease is asymptomatic when it is in the early stages; delayed diagnosis of the disease can lead to poor patient outcome. According to “ Nutrition in Patient with Gastric Cancer: An Update” by Rosania Rosa”, the clinical manifestations associated with gastric cancer are severe/significant weight of greater than 10% within the first six months of diagnosed in 15% of the patient, malnutrition in 80% of the patients, and anorexia-cachexia syndrome are seen in advanced stage of the cancer. Anorexia-cachexia syndrome is “characterized by decreased food intake, hypoalbuminemia, weight loss, and muscle tissue wasting and is associated with increased morbidity and mortality” (Rosania 2016). The anorexia is secondary to the tumor obstruction at the upper GI tract. Therefore, the patients can have signs and symptoms of “dysphagia, early satiety, nausea and vomiting” which may advance the development of malnutrition (Rosania 2016). Hence, identifying and treating malnutrition early through screening can positively impact patient outcome since malnutrition can negatively influence the immune system and cause more adverse clinical manifestations. Patient A for this case study has all the signs and symptoms mentioned above for gastric cancer. Patient A was admitted with worsening nausea, vomiting, and poor appetite. Patient A had ~30 pounds/ 20% severe weight loss in 6 months due to unable to eat solid food secondary to cancer and dysphagia. The dysphagia and weight loss were related to the malignant epigastric mass obstruction of upper GI tract and present with symptoms for frequent nausea, vomiting, and poor appetite while inpatient; Patient A was only drinking sips of the liquid. Upon RD’s first visit, Patient A was diagnosed with malnutrition; The PES statement for malnutrition was severe malnutrition related to inability to consume sufficient energy and protein as evidenced by patient with nausea and vomiting on solid food as well as ~30 lbs/20% (severe) weight loss in 6 months, not meeting within 75% estimated nutritional needs for greater than 1 month. According to “Pocket Resource for Nutrition Assessment 2017th ed” by Elliot Carol, MNT recommends long term enteral nutrition if the patient is unable to consume adequate nutrition greater than 4 weeks due to an impaired ability to ingest food and changes in digestion and absorption. A long-term percutaneous jejunostomy is recommended to bypass the stomach for the gastric cancer patient with dysphagia and obstruction. Hence, Jevity 1.5Cal via J-tube feeding was recommended. Patient A was present with complaint with nausea, vomiting, and abdominal bloating while in-patient . It might be a sign of poor GI tolerance. Since stomach help digest and breakdown most of the complex macronutrients before it is absorbed into the small and large intestine, standard formulas such as Jevity 1.5Cal may cause dumping syndrome or poor digestion to occur due to rapid passage of a large amount of food into the small intestine. Therefore, MNT recommends a specialized formula that is hydrolyzed or predigested into peptides or amino acids for the patients with gastric cancer with poor tolerance to tube feeding (Elliot 2017). Continuous feeding may be recommended to manage tube feeding complications such as diarrhea, constipation, abdominal distention, bloating, high gastric residual, nausea, and vomiting (Elliot 2017). Based on “Pocket Resource for Nutrition Assessment 2017th ed” by Elliot Carol, Vital 1.2Cal may be a better option since it is a highly hydrolyzed peptide-based advanced formula and good for patient with GI intolerance (Abbott 2018-19, page 140).It was great that Patient A was triggered for malnutrition upon admission since early nutrition intervention can influence more positive patient outcome. Better nutrition status can improve recovery, reduced post-surgery complications, and has shorter hospital stay. Besides early nutrition intervention, the quality of nutrition is also very important. According to “Enteral Immunonutrition versus Enteral Nutrition for Gastric Cancer Patients Undergoing a Total Gastrectomy” by Cheng Ying, enteral immunonutrition (EIN) can enhance cellular immunity, modulate inflammatory reaction, and reduce postoperative complications in gastric cancer patient after total gastrectomy. Enteral immunonutrition is to supplement the tube feeding formulas with omega-3, glutamine (Gln), arginine (Arg), and nucleotide. Arginine is semi-essential amino acid that can increase CD4+ T-cell, which could proliferate in response to mitogen or cytokine stimulation; Glutamine is important for intestinal mucosal cell metabolism, and becomes conditionally essential when glutamine depletes rapids when the GI system is impaired; Omega 3 fatty acid is known for its immunomodulatory and anti-inflammatory properties (Cheng 2018). For this case study, Jevity 1.5Cal that recommended to Patient A was not supplemented with omega 3 fatty acids, glutamine, or arginine. Based on findings from the EIN research study, Vital AF 1.2Cal may be a better since it has EPA (2.9g/L) and DHA (1.1g/L) from refined fish oil to help modulate inflammation and support immune function (Abbott 2018-19, page 140). However, it does not have arginine and glutamine as part of the formula. Meanwhile, Juven contains 7 gram of arginine and 7 gram of glutamine per packet (Abbott 2018-19, page 71). Hence, supplementing Juven with Vital AF 1.2Cal tube feeding may improve patient outcome. Even though patient A did not have a total gastrectomy due to the complexity of the tumor and the gastric tumor mass may alter the macronutrient metabolism, providing EIN as early nutrition support may provide a similar benefit. Noted that Patient A also has malnutrition, and malnutrition is “associated with immune function depression, inflammation response alteration, and exaggeration of the stress response.” (Cheng 2018). EIN may help alleviate some conditions of malnutrition. For possible nutrition intervention suggestion for gastric cancer patient in the future, recommending Vital 1.2Cal with Juven via tube feeding may help improve recovery and reduce the length of hospital stay.Patient Profile/ Medical and Surgical Data: Patient A is 64-year-old male, only speaks Cantonese, retired, and lives at home with wife and son. Patient A was admitted to Southern California Hospital at Culver city for worsening nausea, vomiting, and poor appetite, which later diagnosed for gastric cancer. Patient A has a past medical history for recurrent liver hepatocellular cancer, esophageal cancer (squamous cell esophageal carcinoma), thyroid cancer, and hepatitis B. Patient A was diagnosed with hepatocellular carcinoma in 2008, status post liver resection. Patient A received chemotherapy in the past for hepatitis B virus liver cirrhosis. The pathology report reviewed gastric mass biopsy, gastric antrum biopsy, and esophageal biopsy was done on 10/11/2018, which shown the adenocarcinoma are metastatic. The metastatic nature of cancer indicated more cancer cells had spread to other parts of the body, other than the stomach. Patient A was also an ex-smoker. Upon admission, patient triggered for Malnutrition Screening Tool greater than 2 and nausea, vomiting, diarrhea greater than three days; nutrition consult was ordered. Upon admission, Patient A has a temperature of 98.1 degrees Fahrenheit, heart rate of 65 beats/ min, and blood pressure for 124/73. Skin intact per admission nursing notes. No edema noted per Physician History and Physical notes. When patient A was admitted, lab values were performed the next day and reflected the following: Lab values Out of RangeReference RangeHemoglobin 10.5 Low14-16g/dLHematocrit 31.5 Low42-49%MCV95.4 High80.94 fLMCH 31.7 High27-31pgBUN 27 High7-18 mg/dLGlucose 65 Low70-100 mg/dLCalcium8.1 Low8.5-10 mg/dLThe patient is also taking the following medications to alleviate some of his symptoms: MedicationsUse for: IV: 0.9% sodium chloride infusion at 100ml/hrDehydration Ondansetron Nausea and vomiting Patient A was present with various sign and symptoms upon admission and while in-patient, many diagnostic tests were performed to help confirm the medical diagnosis for the signs and symptoms. Table 1: Diagnostic tests performed while Patient A was in-patientDate ProcedureFindings/ Impressions2/27/19CT abdomen + Pelvis with Intravenous Contrast Indication: gastric mass1. Gastrohepatic ligament mass, 9.1 cm (4-27)2. Hepatic metastasis, 2.7 cm (3-19)3. Subcutaneous soft tissue nodule, 1.7 cm (3-39)4. Probable GE junction region lymph node, 1.6 cm (3-12)Large mass centered in the region of the gastrohepatic ligament which may represent an extensive cholangiocarcinoma with secondary involvement of the stomach and gastroesophageal junction or a gastric neoplasm with secondary involvement of the hepatic hilar structures. Severe compression of the portal vein with small collateral vessels. Adenopathy. Hepatic, peritoneal, and subcutaneous metastatic disease. Possible additional pulmonary metastatic disease. and hepatic metastatic disease and there may also be pulmonary metastatic disease.3/5/19CT Liver Percutaneous Needle BiopsyIndication: the presence of questionable liver mass with a subcutaneous metastatic lesionThere is a subtly hyperdense soft tissue nodule within the subcutaneous tissuesof the anterior abdomen.3/6/19US Lower Extremity VenousThere is normal compressibility and flow within the bilateral common femoral,femoral, posterior tibial and popliteal veins.Rule out deep venous thrombosis3/8/19X-Chest Indication: CoughMild bibasilar atelectatic changes.Multiple right upper lobe nodular opacities, suspicious for granulomas..3/9/19XR abdomenIndication: Fever1. Postsurgical changes with midline laparotomy skin staples and right lowerquadrant drainage catheter.2. Nonobstructive bowel gas pattern.3. Left lower lobe alveolar opacities, concerning for pneumonia.3/9/19X-Chest Indication: follow up pneumoniaIncreased left basilar pneumonia.3/11/19XR ChestIndication: bronchitis 1. Lingular, left lower lobe and right lower lobe interstitial opacities,concerning for multifocal pneumonia, increased when compared to the priorexamination.2. Scarring of the right lung apex.3/12/19XR Abdomen AP (KUB)Indication: jejunostomy tube placement verificationAppropriate intraluminal jejunostomy placement.3/13/19US Testicles Indication: scrotal painSmall bilateral hydroceles.Diffuse thickening and heterogeneity of the scrotal wall. Appearance suggestsdiffuse scrotal wall edema. Cellulitis or Fournier's gangrene is not excluded.If further characterization is needed CT could be helpful.3/14/19Echocardiogram 2D CompleteIndication: edemaCardiac activity are normal 3/17/19XR Chest AP 1 View Indication: Shortness of breath.Patchy left lower lung infiltrates.Atelectasis versus mild infiltrates in the perihilar right lower lobe and smallright pleural effusion.Elevated right hemidiaphragm.3/22/19XR Abdomen AP (KUB)-1 View Indication: abdominal pain No evidence of small bowel obstruction The CT abdominal scan indicated the gastric tumor was located at the gastroesophageal (GE) junction. Based on Patient A’s past medical history that he was diagnosed with liver cancer in 2008, the liver cancer might have reoccurred and most likely spread to the stomach, esophageal and lungs since the cancer is metastatic. This also might explain the position of the epigastric mass. Hepatitis B virus and history of smoking may have contributed to the development of liver disease, which later reoccur and spread to other parts of body.Nutrition Screening and Assessment: ADIME ChartingPatient A’s diet upon admission was clear liquid with ensure enlive three times per day with meals. Upon visit, Patient A appeared thin, consistent with BMI, noted slight temporal wasting. Patient A’s son is the translator for the nutrition interview. Son report patient A’s usual body weight is ~130 pounds, and Patient A has ~30 pounds/ 20% severe weight loss in 6 month due to unable to eat solid food secondary to cancer and dysphagia. Son report Patient A with nausea and vomit of solid food before admission and after admission. Per nurse, Patient A was only taking a few sips of liquid on the clear liquid tray. Food allergies for alcohol noted. Table 2 provides an overview of the patient’s general anthropometric information with estimated nutrient needs for energy, protein, and fluids. Patient A is 64 year old male with BMI of 19.7, lower end of normal BMI. Patient A’s nutrient needs need to be calculated to determine if patient is meeting within 75-100% of estimated nutrient needs. Estimated energy needs are calculated based on Mifflin St Jeor equation with activity factor for 1.2-1.3, since patient is bedridden but does not have sepsis. Estimated protein needs are calculated based on 1.2-1.4gm/kg body weight since patient is already 64 year old and BMI is at the lower end of normal range. Estimated fluid needs is based on 1 ml/kcal. Patient A was admitted on February 25 and was discharged on March 25; Table 3 provides the course of events in terms of medical and nutrition care Patient A receives while in-patient, laboratory and medication information are included. Upon admission, Patient A was admitted with nausea and vomiting and was on Clear liquid diet with Ensure Enlive three times daily. A recommendation was made for to advance diet to full liquid diet as tolerated, ensure clear three times daily if the diet was not able to advance, and consideration for tube feeding if possible jejunostomy tube placement. PES statement was made for severe malnutrition related to the inability to consume sufficient energy and protein as evidenced by the patient with nausea and vomiting on solid food as well as ~30 lbs/20% (severe) weight loss in 6 months, not meeting within 75% estimated nutritional needs for greater than 1 month. This PES statement continues while patient A was in-patient because patient have not regained the weight loss at the time of discharge. After patient completed the J-tube placement to bypass the gastric mass, a recommendation was made for Jevity 1.5Cal at 20ml/hr and advance as tolerated every 4-6 hours by 10ml to goal rate of 50ml/hr with 150ml free water flushes every 4 hours for tube patency. At goal rate of 50ml/hr, Patient A would meet within 100% of estimated nutrient need. During in-patient stay, tube feeding was on hold twice upon follow up visit due to Patient A complaint of abdominal bloating, nausea and vomiting. KUB (kidney, ureter, bladder) scans was done twice and shown that J-tube was in an appropriate placement and no bowel obstruction. PES statement was made for inadequate enteral nutrition infusion related to infusion goal rate not reached secondary to nausea and vomiting as evidenced by the patient receiving less than 75% of estimated energy needs and estimated protein needs; this PES statement was resolved when tube feeding resumed. Patient A also developed pressure injury at the sacrococcygeal area but was resolved within a week. Recommendation for Juven once daily for wound healing was made. PES statement was made for Increased nutrient needs related to wound healing as evidence by patient starting to develop sacral wound; this PES statement was discontinued as the patient’s pressure injury resolved on 3/21/19. Before the tube feeding was initiated, nutrition education on adequate protein and calories consumption was explained. After tube feeding was initiated, verbal and written education on J-tube feeding provided. At the time of discharge, Patient A was clinically stable. Patient A discharged with tube feeding and home health services. Per chart, patient wants to hold off on chemotherapy and prefer palliative care with home health. Also, tube management education was provided to the family and patient by nurses. Patient A’s nutrition-related lab values are relatively stable during his in-patient stay(Table 4). Elevated glucose related to dextrose 5% water infusion in addition to tube feeding ( vancomycin with D5W at 250 ml/hr from 3/9 to 3/11 and D5W at 60 ml/hr from 3/11 to 3/19). Elevated BUN likely related to dehydration since patient unable to tolerate food and liquid due to nausea and vomiting; 0.9% sodium chloride infusion at 100ml/hr was provided to rehydration. Sodium level is only slightly out of range, no need to address for depressed sodium. Low hemoglobin and hematocrit triggered for anemia, secondary to malignant neoplasm of digestive organ per discharge note 3/25; iron sucrose was provided to treat the anemia. While in-patient, Patient A did not have many nutrition related medication. In response to dehydration since patient was only taking few sips of liquids, normal saline and dextrose 5% water infusion via IV fluids was provided. In response to nausea and vomiting, ondansetron was provided. In response to constipation and abdominal bloating, docusate sodium, polyethylene glycol, and bisacodyl rectal was provided. In response to the low hemoglobin and hematocrit, iron sucrose was provided. In response to edema, furosemide was provided one time.Appendices: Table 2: Anthropometrics for Patient APatient AAge64 yoGenderMaleHeight154.9cmCBW47.2kgUBW (Before Admission)~130 lbs (59.1kg) per Patient A’s sonBMI19.7 (underweight for older adults greater than 65 yo)IBW; %IBW112lb +/-10% ; 93%Weight History -30#/20% x 6 mo (severe weight loss), UBW: 130# (59.1kg)Estimated nutrient needs based on actual body weightEnergy: 1599-1711kcal (based on Mifflin St Jeor x1.2-1.3)Protein: 57-66gm ( based on 1.2-1.4 gm/kg body weight for underweight status)Fluids: 1599-1711ml (based on 1ml/kcal)Evaluation of intake, current and before admissionPatient A has nausea and vomiting with solid food, and only takes few sips of liquid on clear liquid tray. Table 3: Course of Events During Inpatient Care for Patient ADateMedical Status (only new changes are updated)Nutritional StatusIntervention Monitor and Evaluation (goal) 2/28/19: admissionIV: 0.9% NS at 100ml/hrMeds: ondansetronLab ( 2/27): BUN 21H, Calcium 8.1LCT scan showed gastric mass/suspicious for cancer. Dysphagia and weight loss due to GE junction mass and recommend liquids and Ensure 3x/day per MD notes 2/28. Patient will likely need J-tube placement per GI MD notes 2/27Diet: clear liquid + Ensure enlive 3x/day with mealsUpon visit, patient only takes few sips of liquid and have vomited once. Per son, patient severe ~30 lbs/20% weight loss in 6 month, with usual body weight ~130 lbs and current body weight ~104 lbs.1.Recommended advance diet to full liquid + Ensure Enlive 3x/day with meals 2.If diet unable to advance, consider adding ensure clear 3x/day with meals 3.If J-tube is placed, consider initiating Jevity 1.5 at 20 ml/hr and advance as tolerated every 4-6 hours by 10 ml to goal rate of 50 ml/hr. 150ml free water flushes every 4 hours Nutrition education on adequate protein + calorie consumption explained; family was receptiveMonitor EN tolerance, weight, accu-check, skins, and nutrition related labs Follow up 2x/ weekGoal 1: Patient to meet within 50% estimated nutritional needs by safest diet possible (PO/EN) - not met, continues PES Statement 1Severe malnutrition related to inability to consume sufficient energy and protein as evidence by patient with nausea and vomiting on solid food as well as ~30 lbs/20% (severe) weight loss in 6 month, not meeting within 75% estimated nutritional needs for greater than 1 month - continues while patient A was in-patient, patient have not regain the weight loss at time of discharge3/4/19Follow upLab ( 3/4): Calcium 8.4LPatient was undergoing J-tube placement procedure at time of RD visitDiet: NPO x 1 day for procedure ( J-tube placement)Upon visit, patient was on clear liquid diet for last 5 days with PO intake of 67% with 3 meals on clear liquid diet recorded. 1.Recommended advance diet to full liquid + Ensure Enlive 3x/day with meals 2.If diet unable to advance, consider adding ensure clear 3x/day with meals 3.Once J-tube is placed, consider initiating Jevity 1.5 at 20 ml/hr and advance as tolerated every 4-6 hours by 10 ml to goal rate of 50 ml/hr+ 150ml free water flushes every 4 hours Goal 1: Patient to meet within 50% estimated nutritional needs by safest diet possible (PO/EN) - not met, continues 3/6/19Follow upLab (3/6): H/H 9.3L/28.2L, calcium 8.3LPatient status post J-tube placement without incidence and complicationsDiet: clear liquid + Jevity 1.5 via jejunostomy at 20ml/hr and titrating to goal rate of 50 ml/hr.Observed Jevity 1.5 running at 40 ml/hr upon visit; patient is meeting 83% of estimated energy needs and ~98% of estimated protein needs with tube feeding. Patient only taking sips of juice per nurse. Continue with Jevity 1.5Cal at 40ml/hr via J-tube and advance as tolerated every 406 hours by 10 ml/hr to goal rate of 50ml/hr. Water flushes 150ml every 4 hours. Goal 1: Patient to meet within 50% estimated nutritional needs by safest diet possible (PO/EN) - met, discontinueGoal 2: patient to meet within 75-100% of estimated nutritional needs through enteral nutrition infusion while inpatient. - met, continues 3/8/19Follow upMeds: ondansetron, docusate sodium, polyethylene glycolLabs (3/7): glucose 123H, calcium 7.9L Diet: Jevity 1.5 via J-tube at 50ml/hr. Observed Jevity 1.5 running at goal rate 50ml/hr via J-tube upon visit. Patient is tolerating tube feeding well per nurse.1.Continue with Jevity 1.5Cal at 50ml/hr via J-tube and advance as tolerated. Water flushes 150ml every 4 hours. 2. RD provided verbal and written education on J-tube feeding; family was receptive Goal 2: patient to meet within 75-100% of estimated nutritional needs through enteral nutrition infusion while inpatient - met, continues 3/12/19Follow upIV: D5W at 60ml/hrMeds: ondansetron, docusate sodium, polyethylene glycol, vancomycin, ceftriaxone, iron sucroseLabs (3/12): H/H 9.7L/29.1L, glucose 149H, BUN 21H, calcium 7.7LAccu-check: 107HDiet: Jevity 1.5 via J-tube at 50ml/hr. Upon visit, tube feeding was on hold since last night because patient has abdominal distention. Patient was pending for KUB. Patient have no bowel movement for 2 days.KUB results on 3/12 suggested that J-tube was in the appropriate placement 1.Continue NPO until medically appropriate to reinitiate. Continue order for Jevity 1.5Cal at 50ml/hr via J-tube and advance as tolerated. Water flushes 150ml every 4 hours. 2. If enteral nutrition not appropriate, consult RD for alternate forms of nutrition. Goal 2: patient to meet within 75-100% of estimated nutritional needs through enteral nutrition infusion while inpatient - not met, continues 3/14/19Follow upMeds: ondansetron, hydrocodone, docusate sodium, polyethylene glycol, bisacodyl, vancomycin, iron sucroseLab: (3/13) H/H 9.1L/27.8L; (3/14) glucose 110H, calcium 8LAccu-check: 107H Diet: Jevity 1.5 via J-tube at 50ml/hr. Upon visit, j-tube feeding was running at 50 ml/hr goal rate. Nurse report previous distention contribute by ascites. Nurse will notify MD to discontinue clear liquid as patient currently NPO. Patient’s last bowel movement a day ago.1. Continue order or Jevity 1.5 at 50ml/hr via j-tube and advance as tolerated. Water flushes 150ml every 4 hours. 2. Discontinue clear liquid order Goal 2: patient to meet within 75-100% of estimated nutritional needs through enteral nutrition infusion while inpatient - met, continues 3/18/19Follow upMeds: ondansetron,, docusate sodium, polyethylene glycol, bisacodyl, iron sucroseLab (3/18): H/H 8.7L/25.1L, sodium 133L, glucose 110H, calcium 7.9LDiet: Jevity 1.5 via J-tube at 50ml/hr. Upon visit, j-tube running at 50ml/hr goal rate. Nurse report patient starting to develop a pressure injury1.Continue order for Jevity 1.5Cal at 50ml/hr via j-tube and advance as tolerated. Water flushes 150ml every 4 hours2. Consider adding Juven 1 pack daily for wound healing. Goal 2: patient to meet within 75-100% of estimated nutritional needs through enteral nutrition infusion while inpatient - met, continues PES Statement 2Increased nutrient needs related to wound healing as evidence by patient starting to develop sacral wound - discontinue as patient’s pressure injury resolved on 3/21/193/21/19Follow upLab (3/20) H/H 8.1L/25.1, sodium 135L, glucose 103H, calcium 7.8LPer wound care note 3/21, deep tissue pressure injury to sacrococcygeal area was resolved Diet: Jevity 1.5 via J-tube at 20ml/hr and titrating to goal rate of 50 ml/hr.Upon visit, J-tube feeding on hold because patient feels bloated and still has frequent nausea and vomiting per discussion with son. Tube feeding will be resume soon per nurseContinue order for Jevity 1.5Cal at 50ml/hr via j-tube and advance as tolerated. Water flushes 150ml every 4 hours Goal 2: patient to meet within 75-100% of estimated nutritional needs through enteral nutrition infusion while inpatient - not met, continues Noted tube feeding should resume soon PES Statement 3Inadequate enteral nutrition infusion related to infusion goal rate not reached secondary to nausea and vomiting as evidenced by patient receiving less than 75% of estimated energy needs and estimated protein needs -resolved when tube feeding resumed. Discharge summary (discharged date: 3/25)Patient A was clinically stable, improved, no signs and symptoms of respiratory distress, vital signs were stable and appeared comfortable.Diet: tube feedingJ-tube management education provided to family and patient by nursingDisposition: home health servicePer MD note, patient want to hold off on chemotherapy at this time and prefer palliative care with home health. Table 4: Nutrition Related Laboratory Values during Follow Up’s: HemoglobinHematocrit Sodium Glucose/Accu-checkBUNCalcium Normal values14-16g/dL42-49%136-146 meq/l70-100mg/dL7-18 mg/dL8.5-10 mg/dL2/28/19 admissionLab 2/2721 H8.1L3/4/19 Follow upLab 3/48.4L3/6/19 Follow upLab 3/69.3L28.2L8.3L3/8/19 Follow upLab 3/7123H7.9L3/12/19 Follow upLab 3/129.7L29.1L149HAccu-check: 107H21H7.7L3/14/19 Follow upLab 3/139.1L27.8L110HAccu-check: 107H (3/12)8L3/18/19 Follow upLab 3/188.7L25.1L133L110H7.9L3/21/19 Follow upLab 3/208.1L25.2L135L103H7.8LTable 5: Nutrition Related MedicationsMedicationsRoute of admissionStart dateStop dateFunction Nutrition Implication/ Interaction 0.9% sodium chloride infusion at 100ml/hrIV therapy2/26/193/11/19It provides hydration No nutrient interaction Dextrose 5% water infusion at 60ml/hr IV therapy3/11/193/19/19It provides hydration and calories It provides a source of energy and carbohydrate. May elevate blood sugarOndansetron (Zofran)IV 2/24/193/25/19(discharge)It is used to treat nausea and vomiting (GI disorders)May cause abdominal pain, constipation, diarrhea Docusate sodium (Colace)J-tube3/8/193/25/19(discharge)It is a stool softener and is it used to treat constipation (GI disorder)Diarrhea, cramping, malabsorption of nutrients Polyethylene glycol(Miralax)Oral 3/8/193/25/19(discharge)It is an osmotic laxative, and it is used to treat constipation (GI disorders) Cramping, flatulence, diarrhea, malabsorption of nutrients. Iron sucrose with 0.9% sodium chloride at 400ml/hrIVPB3/11/193/25/19(discharge)It is to treat iron deficiency anemia Hypotension, cramps (especially in thelegs), nauseaBisacodyl Rectal (Dulcolax Rectal)Rectal 3/13/193/25/19(discharge)It is a stimulant laxative for constipation No nutrient interaction Dextrose 50% injectableIV1 time3/4/193/4/19It provides calories and carbohydrate. It provides a source of energy and carbohydrate. May elevate blood sugarFurosemide(Lasix)IV1 time3/19/19319/19It is a diuretic that helps treat cardiac conditions. Hypokalemia, hyperuricemia, anorexia, nausea/vomiting, diarrhea, constipation. Avoid natural licorice. Medications Prior to Admission: NameFunction Nutrition Implication Entecavir Antiviral drugDiarrhea, nausea/vomiting, dyspepsia References Elliott, Carol H, and Brett Conlin. Pocket Resource for Nutrition Assessment. 2017th ed., Academy of Nutrition and Dietetics, 2017. (page 129-139)Piland, Cynthia, and Katheryn Adams. Pocket Resource for Nutrition Assessment. 2009th ed., Academy of Nutrition and Dietetics, 2009. Nelms, Marcia, et al. Nutrition Therapy and Pathophysiology. 3rd ed., Cengage, 2014. Sitarz, Robert, et al. “Gastric Cancer: Epidemiology, Prevention, Classification, and Treatment.” PubMed, PMC, 7 Feb. 2018, ttps://ncbi.nlm.pmc/articles/PMC5808709/. Rosania, Rosa, et al. “Nutrition in Patients with Gastric Cancer: An Update.” Gastrointestinal Tumors, S. Karger AG, May 2016, ncbi.nlm.pmc/articles/PMC4924460/Cheng, Ying, et al. “Enteral Immunonutrition versus Enteral Nutrition for Gastric Cancer Patients Undergoing a Total Gastrectomy: a Systematic Review and Meta-Analysis.” BMC Gastroenterology, BioMed Central, 16 Jan. 2018, ncbi.nlm.pmc/articles/PMC5771223/. Reim, Daniel, and Helmut Friess. “Feeding Challenges in Patients with Esophageal and Gastroesophageal Cancers.” Gastrointestinal Tumors, S. Karger AG, May 2016, ncbi.nlm.pmc/articles/PMC4924457/.Abbott. Abbott Nutrition Product Reference. Vol. 2018-2019, Abbott Laboratories, 2018. (72-73 Juven, 140-141 vital) ................
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