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Stage IIB Esophageal Adenocarcinoma

TB is a 57 year-old female who was recently diagnosed with stage IIB esophageal adenocarcinoma in her lower esophagus. She recently completed radiation and chemotherapy for treatment. She has been admitted to the hospital now for surgical treatment – removal of any remaining tumor. Today is hospital day #2. TB underwent surgical resection of the lower esophagus with the upper esophagus anastomosed to the upper stomach yesterday. The gastroesophageal sphincter was removed along with a small portion of the upper stomach and lower esophagus (see illustration). She is currently stable, intubated and sedated in the surgical ICU. She had a feeding jejunostomy placed in surgery. She has no bowel sounds and has not passed any stool. Her nasogastric tube is putting out 1.2 liters at this time. I.V. fluids via a PICC line running at 100 mL/hr with normal saline & D5W with 20 mEq of KCl. A nutrition consult is requested.

 

Patient History:

Height: 5’9”                   Current Weight:  147 lbs.                      Weight 5 months ago: 175 lbs.

Labs: Sodium: 135 (135-145)     Potassium: 3.8 (3.5-5.5)     Chloride: 103 (99-112)

Bicarb: 26 (22-29)    Fasting glucose: 89 (65-99)    BUN: 11 (8-24)   Creatinine: 0.7 (0.6-1.1)

Albumin: 2.9 (3.5-5.5)    WBC: 13 (4-11)    Hemoglobin: 13 (11-15.8)

Mg: 1.7 (1.5-2.5)        Phosphorus: 2.7 (2.5-4.5)

Vitals: Blood pressure: 130/80      Mean arterial pressure: 66, 65, 67     Temperature: 99°

Meds: IV antibiotic, pantoprazole, and pain meds

Past medical history: breast cancer 10 years ago, gastroesophageal reflux disease and hypertension

Nutrition-focused physical exam: acromion process slightly protruding; depth pinch of triceps/biceps region not ample; some protrusion of clavicle; ribs apparent; and mild depression of inner thigh

Social history: retired attorney; married to CB and has 2 adult children

Nutrition history:

  • Walked 2 miles per day prior to hospitalization
  • Breakfast: 2 scrambled egg whites with 1 oz of cheese and ½ c spinach w/chopped tomatoes. 1 piece of whole wheat toast w/smear of butter and jelly. 4 oz. orange juice and hot tea (8 oz.)
  • Lunch: soup – either chicken noodle or vegetable with ½ of sandwich (either chicken, tuna or egg salad – about a 1/3 of a cup). Small piece of fruit (apple, pear, plum or orange). Hot tea (8 oz.)
  • Snack: 1 ounce of cheddar cheese with 2 triscuits OR some grapes and 10 almonds; hot tea
  • Dinner: 3 oz. of meat, chicken or fish with some type of starch (pasta, rice, or sweet potato – about ½  cup), mixed salad (with greens, carrots, onion, broccoli (all together ~1/2 c) and cran-raisins (1 tsp.)) with 1 Tbsp. fat-free dressing and cooks veggies (~1/2 c). hot tea (10 oz.)
  • Evening snack: ½ c Ben & Jerry’s ice cream OR popsicle OR small chocolate brownie – usually the popsicle

Complete a nutrition assessment (10 points):

Design a nutrition prescription (4 points):

Energy:

Protein:

Fluid:

Micronutrients:

 

Create 2 PES statements (6 points):

P:                                                                                 P:

E:                                                                                 E:

S:                                                                                 S:

A nutrition support consult has been order. Provide your rationale for nutrition recommendations and intervention at this time. (5 points):

Discuss the clinical practice guidelines for initiating enteral nutrition support in an ICU patient without evidence of bowel sounds (hint: see the ASPEN Clinical Practice Guidelines posted on d2l) (5 points):

Complete the following enteral nutrition order form below for TB based on her current clinical status (13 points).

Discuss your rationale for your feeding route, type of infusion method, type of formula and recommendations for initiation and advancement (5 points)

Additionally, discuss your plans for monitoring and evaluation, include follow-up time frame:

(5 points):

Tube Feeding Orders – check the box

Start TF via           ☐  NGT/OGT         ☐  NDT       ☐  NJT         ☐  PEG       ☐  Jejunal tube

Administration:

☐ Continuous                  ☐ Bolus               ☐ Intermittent

Type of Formula:

  Osmolite 1.2: 1.2 kcals/mL, 55.5 grams of protein/liter; 82% free water and meets or exceeds RDIs for micronutrients in 1200 mL
  Jevity 1.2: 1.2kcals/mL, 55.5 grams of protein/liter, 81% free water meets or exceeds RDIs for micronutrients in 1250mL (contains 17g fiber per liter)
  Osmolite 1.5: 1.5 kcals/mL, 63 grams of protein/liter; 76% free water, meets or exceeds RDIs for micronutrients in 1000 mL
  Jevity 1.5: 1.5 kcals/mL, 63.8 grams of protein/liter; 76% free water and meets or exceeds RDIs for micronutrients in 1000 mL
  Pivot 1.5: 1.5 kcals/mL, 93.8 grams of protein/liter; 75% free water and meets or exceeds RDIs for micronutrients in 1000 mL
  Glucerna 1.2: 1.2 kcals/mL, 60 grams of protein/liter, 81% free water, and meets or exceeds RDIs in 1250 mL
  Two Cal HN: 2 kcals/mL, 83.5 grams of protein/liter, 70% free water, and meets or exceeds RDIs in 948 mL
  Vital AF 1.2: 1.2 kcals/mL, 75 grams of protein/liter, 81% free water, 5 gms of fiber/liter and meets or exceeds RDIs for micronutrients in 1185 mL
  Vital High Protein: 1 kcal/mL, 87.3 grams of protein/liter, 84% free water, and meets or exceeds RDIs in 1500 mL
  Nepro: 1.8 kcal/mL, 81 grams of protein/liter, 73% free water, and 12.6 g fiber/L. Low in sodium, potassium and magnesium (<1 g/L). Micronutrient blend designed for renal failure.
  Modular Protein Supplements:

ProSource NoCarb (30mL packet), 15 protein, 60kcals

ProSource Plus (30mL packet), 15g protein, 100kcals

ProCel (1 packet= 5 g pro and 25 kcal)

 

Rate – Initiation & Advancement: 

Initiate TF at ______ mL/hr, advance ______ mL every _____ hours as tolerated to goal rate of _________ mL/hr

Monitoring:

Elevated the head of the bed 30-45°

☐Water flushes w/ ____ mL every ____ hrs

☐Water flush before and after feedings with _____ mL sterile water

☐ Other _______

stage IIB esophageal adenocarcinoma

The post Stage IIB Esophageal Adenocarcinoma appeared first on Nursing Depo.

Stage IIB Esophageal Adenocarcinoma
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