ADIME Note:

Nutrition Services Note

pm

Date:

11/4/2016

Time: 2:40

A: 57 YOM referred by oncologist for TF recommendations. Pt complains of

chronic nausea and loss of appetite. Ambulatory but took leave of absence
from work due to excessive fatigue. Pt s/p PEG tube placement and
dysphagia reports weight loss of 15 pounds in 3 months.
Anthropometrics: Ht: 69 inches (175.3 cm) Wt: 172 lbs. (78 kg)
BMI:
25 kg/m2
UBW: 195 lbs. (88.6 kg), 88% UBW
IBW: 160 lbs (73 kg),
107.5% IBW
Labs: Alb: 3.1 (low), Hgb 9.6 (low), Hct 26.8% (low)
Meds: Ethymol 30 minutes before chemotherapy for reduction of dry mouth,
Cisplatin weekly IV infusions for treatment of squamous cell laryngeal cancer.

Pt had 15-pound weight loss before beginning chemo treatment

assumed due to chronic nausea and lack of appetite (7% weight loss in
3 mo. = severe and suggestive of malnutrition).
Pt lost 2 pounds during first week of treatment and 6 pounds in week 2
(3.4% is severe), assumed due to worsening odynophagia and
stomatitis.
Minimal intake throughout the day (600 kcal/day), 25% of his needs.
Low protein intake (10 g) 8.5% of his needs for the past 7 days.
Assumed due to dysphagia.
Low albumin level (3.1 g/dl) suspect due to infection, inflammation,
and presence of chronic disease.
Low Hct (26.8%) and Hgb (9.6 g/L) suspect due to presence of chronic
disease and anemia.
Mild loss of subcutaneous fat in the orbital pads and triceps suggest
risk for depletion of energy stores.
Mild muscle wasting of the interosseous, clavicular and scapular
regions, along with reduced grip strength indicative of suboptimal
somatic protein status.
Pt is s/p a PEG and may require education about maintaining nutrition
status during cancer treatment
Pt is ambulatory, but has limited his daily activity due to excessive
fatigue.
Pt still engaging in heavy social drinking

Estimated Needs: 2340-2730 kcal/day (Cancer pt, maintenance 30-35

kcals/kg, using current wt); 109 g protein (1.5g/kg using current wt with
increased demands for cancer pt); 2340-2730 ml fluid (30ml-35ml/kg using
current wt).
D: Malnutrition (severe) in the context of chronic disease or condition related
malnutrition (NC-4.1.2) related to chronic nausea, loss of appetite caused by
dysphagia, and worsening odynophagia and stomatitis, as evidenced by
intake meeting only 25% of energy needs, severe wt loss of 7.8% x 3 month,
and mild subcutaneous and muscle loss.
I:
Nutrition Prescription:
Recommend enteral nutrition order of Jevity 1.2 for bolus feedings via PEG, 2
cans QID, as tolerated to meet caloric intake of 2340-2730 kcals, and 109 g
protein requirement. Fluid recommendations of 2340-2730 ml, receiving 807
ml/L of free water in formula, rest in tube flushing with approximately 100 ml
of water before and after tube feeding to meet the rest of his fluid needs.
Goals:
Stabilize weight to minimize muscle and subcutaneous fat loss.
Consume soften fruit and vegetables to increase caloric intake and
maintain function upon approval of SLP and PCP.
Seek out a speech language pathologist.
Maintain weekly visits with RD
Intervention Plan:
Enteral Nutrition: Enteral nutrition site care (ND-2.1.8)
Provided educational information on caring for PEG site.
Feeding assistance: mouth care (ND-4.4)
Collaborate with PCP to provide education on proper mouthwash
technique.
Nutrition education: skill development (E-2.2)
Educate patient and caregiver on proper use and maintenance of
feeding tube.
Pamphlet with instructions on daily care.
Swallowing assessment: Referral to other providers (RC-1.5)
Provided contact information to 2 local private practice speech
language pathologist.
Collaboration with other providers (RC-1.4)

Collaborate with speech language pathologist to find out his tolerances

for future food modifications.
Collaborate with the Pt for appropriate exercise, muscle strengthening
program.
Collaborate with MD if anti-nausea or

M/E:
Pt reacted positively to prescription of tube-feeding and is hopeful it will
alleviate his fatigue and overall condition. Pt showed interest in tracking and
agreed to use daily. Will continue to monitor weight, daily intake values, and
labs weekly.
Materials Provided:

Provided educational information on caring for PEG site

Provided instructions on how to tube feed via PEG
Provided business cards for SLP
Personalized daily food log
Follow up appointment time

Indicator: Enteral nutrition formula (FH-1.3.11)

Criteria: Jevity 1.2, bolus feeding, work toward goal rate: 525 ml/QID to meet
estimated nutritional requirements, monitor enteral nutrition by pt recording
at home intakes.
Indicator: Nutritional Physical findings, cachexia (PD-1.1.1.3)
Criteria: Monitor for adequate calorie-protein intake and changes in muscle
and subcutaneous fat at next appointment.
Indicator: Nutrition-focused physical findings: Mouth: Angular stomatitis (PD1.1.13.2)
Criteria: Conduct regular monitoring of stomatitis and effect on pts QOL.
Monitor pts ability to swallow for future recommendation of pureed foods.
Indicator: Nutrition-focused physical findings: Muscle atrophy (PD-1.1.14.1)
Criteria: Patient reports weekly outcomes of physical ability. Conduct NFPE
for no further loss of muscle in the interosseous, clavicular, and scapular at that
time.
Indicator: Nutrition-focused physical findings: Nausea (PD-1.1.5.24)
Criteria: Pt able to tolerates tube feeding at goal rate without worsening
nausea

Indicator: Nutrition-focused physical findings: Odynophagia (PD-1.1.19.9)

Criteria: Patient reports back from SLP and PCP to assess future oral food
intake.
Megan Menocal, Dietetics Student
123-123-1234