Case Study: Neoplastic Disease (Acute Lymphoblastic Leukemia)

• Understanding the Diagnosis and Pathophysiology

 

1.   What is acute lymphoblastic leukemia (ALL)? Describe the role of blast cells in this disease.

Acute lymphoblastic leukemia is cancer of the white blood cells. This occurs in the bone marrow when there is an overproduction of cancerous, immature white blood cells called “lymphocytes” or “blast cells”. These immature cells multiply, and then damage and kill normal red blood cells, white blood cells, and platelets. This then spreads to other organs throughout the body, causing a decrease of effectiveness and eventually a complete shutdown of the body if not treated.

This cancer is most common in children with an onset between the ages of two and five years, and another peak occurs in old ate. The cause is damage done to the DNA possibly associated with exposure to radiation and chemicals. There is also a type of leukemia called secondary leukemia developed from previous radiation or chemotherapy exposure during prior cancer treatment. Treatments of ALL include chemotherapy, radiation therapy, biological therapy, and immunotherapy (Sheenan P., 2005).

 

2.   What are the signs and symptoms of ALL? Which of these symptoms did Mr. Bear present with when he was diagnosed with his relapse of ALL?

Signs and symptoms of cancer in general include fever, an increased occurrence of infection,  shortness of breath, cough, vomiting, changes in bowel or bladder, increased tendency to bleed, and signs and symptoms associated with malabsorption (anemia being most common: pallor, tachycardia, fatigue, headache) (BOOK, p. 706). More specifically, symptoms of Acute Leukoblastic Leukemia include many of those mentioned above but also include weight loss or loss of appetite, bone or joint pain, edema of the abdomen and lower limbs, petechiae (tiny red spots or lines in skin due to a low platelet count) and an enlargement of the lymph nodes, liver, and/or spleen.

When Mr. Bear was diagnosed with a relapse, he had the following correlating symptoms: fever, fatigue, dyspnea, and red spots on the skin. His condition is progressing as more signs and symptoms have progressed. He now has between 12 and 16 bowel movements daily with green, liquid stool. Also, his skin has a consistent rash and his mucous membranes are blistering and sloughing (Nelms, Sucher, Lacey & Roth, 2011, p. 706).

 

3.   What are the primary goals of high-dose chemotherapy and/or total body radiation in an allogeneic transplant? What are common side effects related to these?

High dose chemotherapy and total body radiation are both part of the conditioning phase for an allogeneic hematopoietic cell transplantation. There are two goals in mind during the conditioning regimen: to eradicate malignant cells and to provide sufficient immunosuppression to decrease the likelihood of rejection of the donor stem cells during engraftment. If done successfully, reconstruction of hematopoiesis and immunity can occur. The conditioning itself can be harmful, however, as well as negative side effects can occur if the patient rejects the transplant. The immediate negative side effects include nausea, vomiting, mucositis, diarrhea, pancytopenia, fever, and infections. Depending on the conditioning, there may be a risk of a decrease in oral intake which may require parenteral nutrition. Tube feeding is not an option in this case as there is a decrease in the immune system which means that they are very much prone to infection. There’s also the consideration of nausea as well as excessive bleeding that can occur because of the lack of platelets.

Other factors to consider for an allogeneic transplant are side effects that may occur long after the transplant. There may be long term tissue damage, which is related to conditioning immunosuppressive agents, and GVHD. These may cause growth retardation, infertility, endocrine failure, avascular joint necrosis, osteopenia, cataracts, renal insufficiency, restrictive pulmonary defects, neurocognitive defects, and secondary malignancies. Delayed gastric emptying may also occur for months after the transplant (Nelms, Sucher, Lacey & Roth, 2011, p. 717).

 

4.   Describe the primary difference among an autologous transplant, an allogeneic transplant, and a synergetic transplant.

There are three different types of donors in hematopoietic stem cell transplants (HSCT). The donor can be the individual undergoing HSCT, a twin, or some other donor who can be either related or not related. An autologous transplant is one in which a patient’s own hematopoietic stem cells are removed and then chemotherapy or radiation therapy occurs. After this therapy, the extracted stem cells in reinfused with the remaining hematopoietic cells. A syngeneic transplant occurs when the patient’s twin is the donor. An Allogeneic transplant involves a non-twin donor who can either be related or not related. These transplants place the patient at the highest risk for transplant-related morbidity or mortality due to secondary GVHD (Nelms, Sucher, Lacey & Roth, 2011, p. 716).

5.   Why do you think Mr. Bear is receiving an allogeneic transplant as opposed to an autologous transplant?

Deciding between autologous and allogeneic transplants depends on the type of malignancy, availability of a suitable donor, the ability to collect a tumor-free auto graft, the stage a status of disease, and the malignancy’s susceptibility to graft versus malignancy (GVM).  Autologous transplants are for patients who are in remission or those whose bone marrow have not been affected by disease. Allogeneic transplants have lower relapse rates, but there are higher chances of the body rejecting the transplant. Mr. Bear was chosen to receive allogeneic transplant because he is not in remission, his bone marrow is being affected by his ALL, and although he has a high risk of GVHD, his chances of success with the treatment are greater with an allogeneic transplant (Nelms, Sucher, Lacey & Roth, 2011, p. 721).

6.   What is the difference between a myeloablative transplant and a non-myeloablative transplant (also referred to as reduced-intensity conditioning [RIC])? In what patient populations would a non-myeloablative transplant be a good treatment option?

A myeloablative transplant consists of high doses of chemotherapy and radiation that results in high immunosuppression. This results in irreversible cytopenia which results in mandatory stem cell support.  A non-myeloablative transplant or RIC involves reduced doses of chemotherapy, radiation, or uses the fludarabine instead as a means of immunosuppression. In this method, cytopenia is minimal may not be irreversible. There is some debate on defining “minimal” radiation and chemotherapy that separate the two methods. Fludarabine, however, is the strictly categorized as RIC. This method is intended for patients ineligible for Myeloblative treatment, due to disease state or being over the age of 50 (American Cancer Society, 2014).

7.   From what three sources can stem cells be collected for a transplant?

There are three primary sources from which stem cells can be collected. The first is the bone marrow and the second is from the bloodstream. Either of these can come from the patient being treated or from a family member or an external donor. This decision is based on the disease state and which treatment will be seemingly most effective. The third source is from the umbilical cord blood from newborns. One in three stem cell transplants are done using umbilical cord blood (American Cancer Society, 2014).

8.   Explain the terms neutropenic and engraftment and their relationship to white blood cell count. What health risks are increased for a neutropenic patient?

Neutropenic is a term used when a patient has an extremely low count of neutrophils, which are white blood cells that fights off infections. More specifically, neutrophils fight off infections caused by bacteria and fungi. Engraftment occurs after a successful transplant when new blood-forming cells start to grow and make healthy blood stem cells. When a patient is neutropenic, bacterial infections are extremely common and viral infections that the immune system had once had under control can resurface (Nelms, Sucher, Lacey & Roth, 2011, p. 703, 715).

9.   Describe graft-versus-host disease (GVHD). Name the cells that the new immune system views as foreign and attacks.

In a high percent of HSCT recipients, graft-versus-host disease (GVHD) occurs. GVHD is when the body rejects the transplant and goes through immunosuppression, organ dysfunction, and infections. The T-lymphocytes of the immune system initiates tissue damage to the skin, liver, and GI tract. This can occur to one or any combination of the three groups of tissues. A sign of the skin being attacked is an erythematous papular rash, and the liver being attacked is denoted by bile duct damage. GVHD can impact any part of the GI tract from dry mouth to oral ulcerations to severe diarrhea. This is why complete nutrition assessments are crucial throughout the transplant.

Acute GVHD is defined as graft rejection within the first 100 days of transplant, while anything that occurs after 100 days is considered chronic. The signs and symptoms of GI GVHD include anorexia, weight loss, nutrient deficiencies, and an increased nitrogen output in the urine. GI GVHD may require parenteral nutrition because of the loss of protein (Nelms, Sucher, Lacey & Roth, 2011, p. 717).

• Understanding the Nutrition Therapy

 

10.   Historically, bone marrow transplant patients were prescribed a low-bacterial diet. What are the current recommendations for the use of this diet during periods of immunosuppression?

During the first six or so weeks after a transplant, until engraftment occurs, a patients is considered to be neutropenic. Antibiotics are often to supplement what the immune system is lacking. Neutropenic diet guidelines should also be followed which includes the avoidance of all uncooked vegetables and fruits (except peeled bananas and oranges), raw or rare meat, undercooked or runny eggs, salad bar and deli counters, solf mold-ripened and blue-veined cheeses, and any water not bottled or boiled. Canned fruits and vegetables are accepted on this diet, as well as any vacuum-packed lunch meat. Also, all dairy products must be pasteurized (Nelms, Sucher, Lacey & Roth, 2011, p. 703, 715).

11.   What are A.S.P.E.N.’s recommendations for nutrition support in hematopoietic transplant patients?

The American Society for Parenteral Nutrition has specific guidelines for those with cancer. This still encompasses the same general guideline of, “If the gut work, use it” as TPN is costly and can be demoralizing. However, there are more specific guidelines as well. According to the ASPEN, patients with cancer should receive nutritional screenings before going through a formal nutritional assessment to develop a nutrition care plan. Nutrition support therapy should not routinely be used adjunct to chemotherapy,  in patients undergoing cancer operations, or in patients undergoing head or neck, abdominal, or pelvic irradiation. The use of palliative treatment (treatment of symptoms without treatment of underlying cause) is rarely a reason for nutrition support therapy and therapeutic diets should not be used to treat cancer.

Situations that include a possible need of nutrition support therapy include moderately to severely malnourished patients 7-14 days prior postoperatively depending on weighed risk factors as well as malnourished patients who are receiving anticancer treatment and are anticipated to be unable to ingest or absorb adequate nutrients for an extended period of time. When using nutrition support therapy, omega-3 fatty acid supplementation may help stabilize weight in cancer patients experiencing progressive, unintentional weight loss. Also, immune-enhancing enteral formulas containing mixtures of arginine, nucleic acids, and essential fatty acids may be beneficial. However, in Mr. Bear’s case, this would have to be monitored so to not interfere with his immunosuppression (Nelms, Sucher, Lacey & Roth, 2011, p. 726-727).

 

12.   Describe a situation in which TPN is appropriate in hematopoietic cell transplant patients and a situation in which enteral nutrition should be used.

Total parenteral nutrition is only to be used when moderate to severe GI GVHD occurs. This is necessary because of the elevated energy needs. The patient will also have increased protein needs due to GI loss, possible dermal losses, and extra protein will be needed to meet protein synthesis needs. Gluticosteroids, and immunosuppressor, also cause a loss of nitrogen through the urine, which is a loss of protein. The use of enteral nutrition is contraindicated. If GI GVHD is resulting in severe delayed gastric emptying, or if there is severe damage of the GI mucosa, enteral nutrition should be used (Nelms, Sucher, Lacey & Roth, 2011, p. 716).

13.   State the long-term nutritional implications associated with the chronic use of corticosteroids for the treatment of GVHD. Mr. Bear will be discharged on steroids. What should you encourage him to eat and what supplement may he need to take?

Corticosteroids are used to inhibit inflammatory and immune responses. Chronic use of corticosteroids can cause many different side effects that require nutrition intervention. These side effects include osteoporosis or loss of bone density, fluid retention and high blood pressure, hyperglycemia or steroid-induced diabetes, and weight gain associated with increased appetite. Each of these can be prevented with supplementation and nutrition intervention. Consumption of pasteurized low-fat milk, cheese, and yogurt as well as calcium and vitamin D supplement help combat osteoporosis. For fluid retention and high blood pressure, salt intake should be limited to 600 mg or less per entree. Large portions of foods high in simple sugars should also be avoided to reduce the risk of extreme blood sugar changes, and these calories should be replaced with whole grain complex carbohydrates. To help curb appetite and avoid unnecessary weight gain, meals should be small, spread out and contain foods low in sugar and fat. Lean proteins, fruits, and vegetables should be consumed.

Source(s): American cancer society

14.   Assess Mr. Bear’s height and weight. Calculate his BMI and % IBW.

Weight = 198 lbs / 2.2 = 90 kg

Height = 5’9” = 69 in X 2.54 = 175 cm or 1.75 m

 

BMI = wt. (kg) / ht (meters) squared

= 90 / (1.75)²

= 29.4

This BMI falls into the classification of overweight.

IBW (Hamwei Method)

106lbs + (6 lbs for every inch over 5 foot)

= 106 + (6 X 9)

= 160

 

% IBW = (100 X Actual Body Weight) / Ideal Body Weight

= (100 X 198) / 160

= 124%

III. Nutrition Assessment

15. Determine Mr. Bear’s energy, protein and fluid requirements

Energy Needs

The Mifflin- St. Jeor for men is used to calculate Mr. Bear’s resting energy expenditure.

Weight = 90 kg

Height = 69 in

Age = 28 years

Mifflin- St. Jeor

REE= 10 x weight (kg) + 6.24 x height (cm) – 5 x age (years) +5

REE= (10 x 90 kg) + (6.24 x 175.3 cm) – (5 x 28) +5

REE= 1848.9 kcal/ day

Total Energy Requirements

PAL= 1.5 (stress factor treatment recovery)

1848.9 kcal/ day x 1.5

TEE= 2773.4 kcal/day

 

(Nelms, Sucher, Lacey & Roth, 2011, p. 595)

Aside from the Mifflin- St. Jeor formula, another equation can be used for Mr. Bear since his current BMI of 29 almost qualifies him as obese. In addition to his high BMI, his 48- hour food recall stated that he is already meeting 100% or more of his calorie intake (Nahikian-Nelms, M., & Roth, S. L., 2013, p. 383). In order to maintain his current weight and make treatment most effective, it is suggested that he consumes less calories than the Mifflin- St. Jeor recommends. It is suggested that cancer patients who are obese consume between 21-25 kcalories/kg. Since Mr. Bear’s BMI is not considered obese yet (BMI=30+), I would calculate his energy needs based off 25 kcalories/ kg according to Nelms, page 719

25 kcal/kg x 90 kg

=2250 kcal/day

Protein Requirements

Although the patient’s 48 dietary recall states that he is receiving 100% or more of his protein requirements, his lab results did not reflect this (Nahikian-Nelms, M., & Roth, S. L., 2013, p. 383). His protein needs should be very high to prevent or reduce negative nitrogen balance in order to meet protein synthesis needs. Also, he is having diarrhea so is likely not absorbing all the protein he is consuming. It is recommended that Hematopoietic Cell Transplantation patients consume 1.5 grams of protein /kg of body weight (Nelms, Sucher, Lacey & Roth, 2011, p. 721).

.

Grams of protein/day

90 kg x 1.5 g/kg

= 135 grams of protein/day

Calories of protein/ day

135 g/day x 4kcal/ 1g of protein

=540 calories of protein/day

*According to his calculated energy requirements based off 25 kcalories/ kg, his total protein needs would account for 25% of his total calorie intake.

(540 kcal of protein / 2250 total kcal)

Fluid Requirements

Mr. Bear’s fluid needs should be between 30-35 mL/kg to reduce his risk of dehydration during treatment. Since he will be undergoing HSCT following TBI (total body irradiation) and is experiencing extreme diarrhea as well as some nausea (Nahikian-Nelms, M., & Roth, S. L., 2013, p. 384), it would be best to use the higher value of 35 mL/kg to assess his fluid needs. (Nelms, Sucher, Lacey & Roth, 2011, p. 721).

90 kg x 35 mL/kg

= 3150 mL of fluid/ day

16. On admission, did Mr. Bear present with any nutrition risk factors?

Mr. Bear presents many nutrition risk factors that are of concern including his tobacco use of ½ pack daily as well as his alcohol use of 1 drink daily. These lifestyle choices place him at a high risk for relapse, as well as his past history of obesity since these factors are shown to have a direct relationship to cancer risk. Although it is unknown if his parents were overweight or obese, the oncology history states that his mother had diabetes as well as hypertension. His family history of these chronic diseases likely contributed to the development of his unhealthy lifestyle leading to a past history of obesity and current overweight status, which placed him at high risk for developing acute lymphoblastic leukemia. The patient states in his nutrition history that his usual body weight is around 230 lbs, which would qualify him as obese (BMI= 33.9). Chemotherapy in 2008 resulted in extreme weight loss of 50 lbs., but he has maintained a weight of 200 lbs. within the following year of chemo. His 48 hour food recall states that he is meeting 100% or more of his calorie or protein needs which is likely contributing to his inability to maintain a healthy weight (Nahikian-Nelms, M., & Roth, S. L., 2013, p. 384).

 

 

17. Prior to completing your nutrition assessment for his admission, you go and talk with Mr. Bear. Please list 2 additional questions you would ask him and give a reason why you chose each question.

Question #1: “Can you name some foods that increase your nausea and ones that limit or suppress it?”

 

-I would ask the patient about his food preferences during treatment so I have a better understanding of what types of food to include in his diet while he is recovering from treatment. I would want to limit his nausea and possible vomiting and diarrhea by giving him foods that he is comfortable eating throughout treatment to decrease chances of malabsorption from the side effects of TBI.

Question #2: “Who prepares the foods in your house and goes grocery shopping?”

-It would be important to find out the food habits in his home and discover his role in food preparation. The more he is willing to take on an active role in changing his bad health habits, the more he will succeed. Also, it would be beneficial to find out what support he has at home and if his wife/ kids would be able to help him change his eating habits to lose weight.

18. Look at the MD note, labs and RN documentation from 11/30. What nutrition risk factors has the patient developed? For each, name a reason why he may have developed this risk factor.

According to the MD progress note for 11/30, his stool output is extremely high and indicates he is likely experiencing dehydration as well as malnutrition. His stool output was recorded at 3500 mL in the previous 24 hours, significantly higher than the average adult’s stool output of 200 mL. High doses of TBI often result in side effects such as diarrhea and are often seen right after the conditioning regimen is administered. A high volume of diarrhea places Mr. Bear at a high risk of macronutrient and micronutrient malabsorption. (Nahikian-Nelms, M., & Roth, S. L., 2013, p. 383).

His abnormal lab results include his Blood Urea Nitrogen (BUN) reading (23 mg/dL, normal= 8-18) as well as his BUN/ Crea ratio (23, normal= 10-20). His magnesium, albumin, prealbumin and hematology results were all below the reference ranges. Monocyte % was elevated and Blasts % was low. His high BUN and magnesium levels are likely elevated due to his dehydration. His decreased urine output is due to hypovolemia, which is extracellular fluid deficit related to renal or extra renal loss of fluids (Nelms, Sucher, Lacey & Roth, 2011, 126). His dehydration was shown in his orange urine sample, which means his urine is concentrated. A decrease in prealbumin and albumin are expected due to his cancer and put him at high risk for protein deficiency since he is not absorbing enough protein. (Nahikian-Nelms, M., & Roth, S. L., 2013, p. 384-386).

 

19. Review the MD note from 11/30. List the names and actions (benefits for this patient) of all the medications that are mentioned in the doctor’s note. List the major nutrition side effects for the following: methylprednisolone, morphine/ hydromorphone, and scopolamine patch.

Lorazepam (administered 0.5-1 mg po every 8 hours) is classified as a benzodiazepine and will help relieve the patient’s anxiety by slowing down brain activity. It is also used in cancer treatment to treat nausea and vomiting (Lorazepam, 2010). Docusate (administered 100 mg po, twice daily prn) is a stool softener that will help relieve the patient’s constipation caused by other medications such as morphine and lorazepam (Docusate, 2010). Oxycodone (administered 5 mg po every 4 hrs prn) is a strong pain reliever that will be used to help manage the painful side effects of treatment. It acts similar to morphine by binding to the opioid receptors in the brain and central nervous system to reduce the perception of pain and the emotional response to it.  It can be used for both long term cancer pain treatment and as a short term pain reliever (Oxycodone, 2014). Senna (8.6 mg daily prn) is a stimulant laxative that will be used to alleviate the patient’s constipation by increasing the activity in the small intestines (Senna, 2011).  Methotrexate is in a class of medications called antimetabolites and is used to treat cancer by slowing down the growth rate of cancer cells (Methotrexate, 2014). It is used in acute and chronic GVHD and will act as an immunosuppressant (Nelms, Sucher, Lacey & Roth, 2011, pg. 717).

Drug Name	Classification	Generic	Nutrition Side Effects
methylprednisolone	Anti-inflammatory hormone	Corticosteroid	Increased appetite, indigestion, increased thirst (Nelms, Sucher, Lacey & Roth, 2011, pg. 596).
morphine/ hydromorphone	Analgesic	Opioid	Constipation, nausea, vomiting
Scopolamine patch	anticholinergic agent	Anti-nausea	Dry mouth (Scopolamine Transdermal Patch, 2014)

20. The MD note from 11/30 mentions that Mr. Bear’s mucositis is improving. Why do you think it is starting to improve?

Mr. Bear’s mucositis is likely induced from the chemotherapy and often continues until immunosuppression recovery occurs. On 11/30, his mucositis was beginning to slowly improve due to administration of morphine and hydromorephone prn to manage pain and mouth care. Use of  good oral hygiene and oral glutamine are beneficial treatments and likely caused the improvement of the patient’s muscositis. (Nelms, Sucher, Lacey & Roth, 2011, pg. 723)

1. Nutrition Diagnosis
2. Identify the pertinent nutrition problems and the corresponding nutrition diagnoses for Mr. Bear upon his admission on 11/7.

•      Overweight (adult): NC-3.3
•      Physical inactivity: NB- 2.1
•      Excessive Energy Intake: NI 1.3
•      Unintended Weight loss: NC- 3.2

(Academy of Nutrition and Dietetics, 2014)

21. Write PES statements for each high-priority nutrition problem that you have identified for Mr. Bear upon his admission on 11/7.

Overweight (adult): NC-3.3

-Overweight related to excessive energy intake as evidenced by BMI of 29

Physical inactivity: NB- 2.1

-Physical inactivity related to chronic conditions that reduces physical activity or activities of daily living as evidenced by medical history of obesity, anxiety, depression, osteomyelitis, back pain

Excessive Energy Intake: NI 1.3

– Excessive oral intake related to food and nutrition related knowledge deficit as evidence by 48 hour recall showing patient is meeting > or = to 100% of calorie and protein need

Unintended Weight loss: NC- 3.2

-Unintended Weight loss from normal weight of 230 lbs. related to acute lymphoblastic leukemia diagnosis as evidenced by chemotherapy treatment and loss of 50 lbs (22% of body weight)

1. Nutrition Intervention
2. Design a parenteral nutrition support regimen for Mr. Bear based on his labs from 11/30. Calculate the dextrose, lipids and amino acids for his parenteral solution.

Based off 2,770 calories

1 mL/kcal= 2770 mL

Fat

10% lipid: 2770 x 0.30= 831 kcal

30% lipid: 831/ 11 kcal/g= 75.5 g

76/ 2770 x 100= 2.74% lipid or 27 g per liter

Protein

=  135 grams of protein/day

135/ 2770 x 100= 4.87 % amino acid solution

Dextrose

135 g protein x 4 kcal/g = 540 kcal

76 g lipid x 11kcal/g= 836 kcal

540+836= 1376 from lipid and protein

2770-1376= 1394 from dextrose

1394/3.4 = 410 g

410/2770 x 100= 14.8 ~ 15% dextrose

*Parental nutrition to provide 135 grams of protein at 4.9% of solution, 76 grams of fat at 2.7% solution and 410 grams of dextrose at 4.9% solution.

(Nelms, Sucher, Lacey & Roth, 2011, pg. 100)

 

 

24. Mr. Bear and his family have asked to meet with you; they want to know why he need TPN. How would you explain his need for TPN?

Mr. Bear’s need for TPN can be explained due to decreased nutrient absorption caused by his high volume diarrhea (12-16 bowel movements). He is no longer allowed to consume anything PO due to his diarrhea and to get ready for his GI test (Nahikian-Nelms, M., & Roth, S. L., 2013, p. 384). TPN is necessary to make sure Mr. Bear receives all the necessary nutrients and fluid intake and maintain his weight. The assessment/ plan for 11/30 states that he has occasional nausea and that he is on tacrolimus for GVHD prophylaxis. His TPN regiment should be enriched with glutamine to provide energy for the gastrointestinal epithelial cells and immune cells to positively benefit his nutrition status. Total parenteral nutrition would be preferred to enteral nutrition as of now due to his extreme GI stress. Tube feeding would not be successful because the patient is experiencing nausea, diarrhea and has mucositis. In addition, the patient’s lab values reveal low platelet count and the insertion of a feeding tube may cause bleeding and result in an infection due to his suppressed immune system. (Nelms, Sucher, Lacey & Roth, 2011, pg. 717). Once GI biopsy is completed and presence of GVHD is determined and treated, a GVHD diet can be implemented.

 

25. Mr. Bear’s gut biopsy came back positive for GVHD. Once his diarrhea has resolved, how would you recommend that his diet be advanced?

Once Mr. Bear’s diarrhea has resolved, the patient should discontinue PN and advanced to a low-bacteria diet. The purpose of the low-bacteria diet is to avoid and GI stress while in remission. The diet suggests that GVHD patient’s avoid fresh fruits and vegetables to reduce the risk of foodborne infection. Also, the patient should only drink bottled water to avoid infection and infestation if a filtration system is unavailable. In addition to these precautions, raw or rare cooked meats should be avoided, shellfish, yogurt products with live cultures, buffets, salad bars as well as perishable food items from street vendors (Sheenan, P., 2005). Those following a low-bacteria diet should also be extra cautious of food holding temperatures and the internal doneness when cooking foods that have a recommended cooking temperature. (Nelms, Sucher, Lacey & Roth, 2011, pg. 595).

1. Nutrition Monitoring and Evaluation
2. What labs would you want to make sure are ordered now that TPN is being started? Do you think measuring nitrogen balance would be helpful for this patient at the time? Why or why not?

I would want to monitor his blood glucose levels and make he does not develop TPN induced glycemia with a blood glucose level >120 mg/ dL (Sheenan, P., 2005). His weight, electrolyte levels, BUN levels should be monitored daily as well as his fluid intake and output. I think measuring the patient’s nitrogen balance, albumin and prealbumin would definitely be helpful to assess the patient’s improvement. If his nitrogen levels increase and become less negative, this would indicate the patient’s body is started to accept the treatment and heal. Albumin and prealbumin levels would help monitor the patient’s protein needs and if they should be increased or decreased based off lab results.

27. Mr. Bear’s blood glucose has increased, and now ranges from 280- 410-mg/ dL. What could be contributing to this sudden increase? What changes could you make to the TPN to improve his blood sugar values?

His sudden increase in blood glucose is likely due to his the high amount of dextrose he his receiving through parenteral nutrition.  In order to improve Mr. Bear’s hyperglycemia of 280-410 mg/dL, I would decrease his dextrose from 410-grams/ day to about 300 grams (Tilton, J., 2011). To ensure the patient is still getting enough calories, I would replace the calories from dextrose and amplify his protein and slightly increase his fat.

 

 

References

Academy of Nutrition and Dietetics. (2014). eNCPT- Nutrition Terminology Reference Manual. Retrieved from http://ncpt.webauthor.com/pubs/idnt-en/

American Cancer Society. Cancer Facts & Figures 2014. Atlanta: American Cancer Society; 2014. Retrieved October 1, 2014, from http://www.cancer.org/acs/acspc-042151

Docusate. (2010, December 15). Retrieved October 1, 2014, from http://www.drugs.com/mtm/docusate.html

Lorazepam. (2010, October 1). Retrieved October 1, 2014, from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682053.html

Methotrexate. (2014, May 15). Retrieved October 1, 2014, from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682019.html#why

Nahikian-Nelms, M., & Roth, S. L. (2013). Medical nutrition therapy: A case study approach. Stamford, Connecticut: Cengage Learning.

Nelms, M., Sucher, K. P., Lacey, K., & Roth, S. L. (2011). Nutrition therapy and pathophysiology. Belmont, CA: Wadsworth, Cengage Learning.

Oxycodone. (2014, June 18). Retrieved October 1, 2014, from http://www.cancer.org/treatment/treatmentsandsideeffects/guidetocancerdrugs/oxycodone

Scopolamine Transdermal Patch. (2014, September 24). Retrieved October 1, 2014, from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682509.html

Senna. (2011, November 15). Retrieved October 1, 2014, from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601112.html

Sheenan, P. (2005, April 1). Nutrition Support of Blood or Marrow Transplant Recipients: How Much Do We Really Know? Retrieved September 30, 2014, from http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/0405-newsletter.pdf

Tilton, J. (2011, August 1). Benefits and Risks of Parenteral Nutrition in Patients with Cancer. Retrieved October 1, 2014, from http://media.oncologynurseadvisor.com/documents/26/ona_feature-pn0811_6351.pdf