case study 1 (Q3)

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 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.

3. A) INTRODUCTION
Terms Description
Metastasis Adenocarcinoma neck cancer usually begins in the squamous
Adenocarcinoma cells that line the moist, mucosal surfaces inside the head and
neck 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
ASSESMENT
2. ANTHROPOMETRY DATA
Height
172 cm
Weight
63 kg
BMI
21.3 kg/m (normal)

6. B) NUTRITIONAL STATUS
ASSESMENT
3. BIOCHEMICAL DATA
Parameter Data Reference Indication Explaination
Range
Sodium 125 mmol/L 135 - 145 Low Indication of overhydration
mmol/L
Potassium 3.6 mmol/L 3.5 – 5.1 Normal -
mmol/L
Urea 2.7 mmol/L 2.9 - 7.9 Low Indication of malnourish. Also due to low
mmol/L 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 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 statement
Poor oral intake related to dysphagia as
evidence by loss of 5 kg of body weight

10. D) INTERVENTION
Objectives Principles
1. To provide adequate calorie •Introduce suitable enteral feeding 6 times per day
intake to prevent further
weight loss
2. 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 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

12. D) INTERVENTION
1. 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

13. D) INTERVENTION
2. Calculation requirement of
PRO CHO FAT
1.5 g/kg/day x 63 kg =
94.5 g/day 57 x 2442 kcal = 1391.9 kcal 27 x 2442 kcal = 659.3 kcal
94.5 d/day x 4 kcal =378 100 4 100 9
kcal
378 x 100 kcal = 15.48 % = 348 g/day = 73.3 g/day
2442
≈ 15.5
So, we choose 16 % of
protein/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 g
Dilution 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 g
Introduce 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 g
Introduce
1.+ 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 g
GOAL 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 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.

22. E) ADDITIONAL INFO