Your Name and/or Name of Partner (if working with one): 7randi 4ofmann

University of Minnesota - Department of ood !"ien"e # Nutrition FScN 4665 - Medical Nutrition Therapy I - Fall 2013 Case 4

$%% Points ue ate! Thursday" ece#$er 5 P&ease 'e sure to do the fo&&owing: !how a&& "a&"u&ations( and e)p&ain your rationa&e* +a&"u&ations do not have to 'e typed* ,nswer a&& -uestions dire"t&y on this form* .ype a&& answers (e)"ept "a&"u&ations)* !u'mit in hard "opy in "&ass on the due date* You wi&& 'e dedu"ted one point per day after the due date unti& the hard "opy is turned in* You may work ,/0N1 or with 0N1 other person* Do not share your work with other individua&s 'eyond your group* 2f you work with a partner( you shou&d hand in on&y 0N1 "ase with your name and your partner3s name "&ear&y &isted at the top of the first page* !ome resour"es needed for so&ving the +ase: $* /e"ture notes on Nutrition ,ssessment 2-4istory and Physi"a& 1)amination 5* /e"ture notes on Nutrition ,ssessment 22- ,nthropometry 6* /e"ture notes on Nutrition ,ssessment 222-7io"hemi"a&//a'oratory 8* Modu&e 2: Nutrition +are Pro"ess( Nutrition Diagnosis and Medi"a& 9e"ord Do"umentation :* Modu&e 22: 1nergy( Protein( and &uid 9e-uirements in the +&ini"a& !etting ;* Modu&e 222: ,n 2ntrodu"tion to the 1)"hange /ists for Mea& P&anning <* Modu&e =: +an"er >* ,"ademy of Nutrition and Dieteti"s: 1viden"e ,na&ysis /i'rary Nutrition ?uide&ines (0n"o&ogy%* /ink to the 1,/ we'site is posted in Mood&e @* 2DN. Manua& $%* Arause3s ood and the Nutrition +are Pro"ess( $6th edition* +hapter 6<: Medi"a& Nutrition .herapy for +an"er Prevention( .reatment( and 9e"overy* The Case o& Ms' Scenario! , :%-year-o&d woman (Ms* D) presented with a $ month history of fever( weight &oss( 'one pain( and easy 'ruising* 4er primary "are physi"ian "he"ked routine '&ood work( and she was found to have pan"ytopenia( with a &ow white '&ood "e&& "ount( &ow hemog&o'in( and &ow p&ate&ets* , 'one marrow 'iopsy was performed( whi"h "onfirmed the diagnosis of a"ute mye&ogenous &eukemia (,M/)* 4er weight at that point was $56 &'s* !he was initiated on indu"tion "hemotherapy( 'ut unfortunate&y did not respond* 4er 'rother was found to 'e a 4uman /euko"yte ,ntigen (4/,) mat"h( so she su'se-uent&y underwent an a&&ogenei" $

hematopoieti" stem "e&& transp&antation (4!+.) 5 months &ater* ,t that point( her weight was down to $$8 &'s* 4er posttransp&ant "ourse was "omp&i"ated 'y severe mu"ositis( ne"essitating PN support* 4er mu"ositis s&ow&y improved( and she was to&erating an ora& neutropeni" diet 'y day $8 and PN was dis"ontinued* !he engrafted on day 5$* 0n day 8:( she deve&oped nausea( vomiting( and profuse diarrhea with an ina'i&ity to to&erate ora& intake* ,n a'domina& =-ray was negative for o'stru"tion( and stoo& studies were negative for infe"tion* !he su'se-uent&y underwent a "o&onos"opy and upper endos"opy that "onfirmed severe graft-versus-host-disease (?B4D) of the ?2 tra"t* .he 9D is "onsu&ted to initiate PN* Current (nthropo#etric ata! Height: :3<C Admission weight: $$8 &'s Weight six months prior to admission (UBW): $6% &'s )hysical *+a#ination! Signs of temporal and orbital wasting; poor skin turgor Blood pressure: !"! mm Hg Bio#hemi#al $ata: ,a$ Test ?&u"ose NaD AD 7UN +r Phosphorus MgDD +a&"ium ,&'umin +urrent $5: $:% 6*5 5: %*@ 5*> $*8 > 6*% Nor#al -an.e <% - $$% $6; - $8: 6*: - :*% > - 5: %*; - $*: 6*% - 8*: $*: - 5*: @ - $$ 6*: - :*% /nits mg/d/ m1-// m1-// mg/d/ mg/d/ m1-// m1-// mg/d/ g/d/

/N *-ST(N IN0 T1* )(T12)13SI2,203 (N T-*(TM*NT $* Ms* D was put on a Eneutropeni"3 diet after her 4!+.* Fhat is the rationa&e for re"ommending Eneutropeni" pre"autions3 for a&& patients who have undergone 4!+.( in the post-transp&ant periodG (6 points) Patients who have undergone 4!+. are more &ike&y to 'e immuno"ompromised 'e"ause of a redu"ed white '&ood "e&& "ount* , nuetropeni" diet is suggested for post-transp&ant 4!+. patients in an attempt to redu"e their risk of infe"tion 'y redu"ing the num'er of foods that are at risk of "ontaining a high &eve& of 'a"teria or mi"ro'es*

5*

Fhat are the genera& "hara"teristi"s of a neutropeni" dietG (8 points) ,""ording to the Arause te)t( neutropeni" diets avoid foods that may have unsafe &eve&s of 'a"teria( su"h as raw meats( spoi&ed or mo&dy foods( and unpasteuriHed 'everages* Patients on a neutropeni" diet shou&d re"eive edu"ation regarding hand&ing of raw meats( game( pou&try( eggs( utensi&s( "utting 'oards( and "ountertops* .hey shou&d a&so &earn a'out storing foods at appropriate hot and "o&d temperatures and avoid untested we&& water*

6*

Name at &east one e)amp&e of a high-risk food (in terms of a spe"ifi" item( or in terms of genera& preparation/hand&ing "hara"teristi"s) within the $) M2/A/D,29YI 5) M1,.I 6) 9U2. and 8) B1?1.,7/1 "ategories* (8 points) M2/A/D,29Y: unpasteuriHed mi&k M1,.: under"ooked or raw meats 9U2.: fresh fruit B1?1.,7/1: sa&ad 'ars

8*

Fhat is graft-versus-host-disease (?B4D)G (5 points) ?B4D is a "omp&i"ation of patients that have had transp&ants in whi"h a donor stem "e&& rea"ts adverse&y with host tissues* .his disrupts the fun"tion of many target organs that are sus"epti'&e to infe"tion* 2t "an o""ur in as &itt&e as a week post-transp&ant* 2t "an a&so reso&ve on its own or deve&op a "hroni" "ondition*

:*

Dis"uss the nutritiona& "omp&i"ations of ?B4D of the gastrointestina& tra"t* 4ow is ?B4D of the gastrointestina& tra"t most "ommon&y managed nutritiona&&yG (; points) ?2 ?B4D "an "ause gastroenteritis( a'domina& pain( nausea( vomiting( and a &arge vo&ume of se"retory diarrhea* 6

?2 ?B4D is managed in five phases* 2n the initia& phase( the patient is pres"ri'ed 'owe& rest and a parentera& nutrition regimen unti& diarrhea su'sides* 2n the se"ond phase( patients are reintrodu"ed to ora& feedings of isosmoti"( &ow-residue( and &a"tose-free &i-uids to "ompensate for the &oss of intestina& enHymes( se"ondary to a&teration in intestina& vi&&i and mu"osa* 2f the 'everages provided in the se"ond phase of treatment are to&erated( &ow-&a"tose( fi'er( fat( and a"id foods are reintrodu"ed* ?astri" irritants are sti&& avoided at this point* 2n the fourth phase( dietary restri"tions are redu"ed 'ased on food to&eran"e and progression* 2n the fifth and fina& phase( the patient resumes their regu&ar diet* ;* Fhat is mu"ositisG Fhat are some nutritiona& strategies to manage mu"ositis among "an"er patientsG (9efer to the 42B/,2D! notes( as we&& as .a'&e 6<-: in Arause te)t) (8 points) Mu"ositis is the inf&ammation of the mu"ous mem'ranes &ining the oropharyn) and esophagus* 2t is a "ommon side effe"t of many "hemotherapies* !ome of the nutritiona& strategies for managing mu"ositis in"&ude keeping the mouth "&ean and avoid to'a""o( a&"oho&( and irritating foods* 7&and rinses shou&d 'e used to improve ora& hygieneI these in"&ude 'aking soda and sa&ine rinses* 7&and &i-uids and soft so&ids are typi"a&&y to&erated in patients suffering from ora& and esophagea& mu"ositis* !trong-f&avored a"idi" and spi"y foods shou&d 'e avoided* +ommer"ia&&y prepared &i-uid medi"a& food supp&ements may 'e usefu&* (nthropo#etric ata <* ,* +a&"u&ate Ms* D3s Jidea&C 'ody weight using the 4amwi e-uation* (5 points) Ms* D3s idea& 'ody weight is $6: &'s K$%L

7* +a&"u&ate the L Jidea&C 'ody weight and L usua& 'ody weight she is at her "urrent weight* (8 points) ,t her "urrent weight( Ms* D3s L idea& 'ody weight is >8*8L

4er L usua& 'ody weight is ><*<L

+* +a&"u&ate Ms* D3s 7M2* 2nto whi"h "ategory does she fa&&( 'ased upon the Nationa& 2nstitutes of 4ea&th( Nationa& 4eart( /ung( and 7&ood 2nstitute3s +&ini"a& ?uide&ines on the 2dentifi"ation( 1va&uation( and .reatment of 0verweight and 0'esity in ,du&ts( whi"h was provided in the JNutrition ,ssessment 22: ,nthropometryC notesG (5 points) 7ased on her "urrent 'ody weight( Ms* D3s 7M2 is $<*@* .his is "&assified as 'eing underweight( with norma& 7M2 'eginning at $>*:*

D* %&aluate Ms* D3s "urrent weight in terms of "hange from usua& 'ody weight over time ('e spe"ifi")* 2f she has &ost weight( is it "&ini"a&&y signifi"antG 1)p&ain* (8 points) Ms* D has &ost $5*6L of her 'ody weight in the past ; months* .his is "&ini"a&&y signifi"ant and is "onsidered severe weight &oss( as anything over $%L in ; months is "onsidered "&ini"a&&y severe*

N/T-ITI2N I(0N2SIS >* 9efer to the ,!P1N/,"ademy +onsensus !tatement (Fhite MB( ?uenter P( Mensen ?/( Ma&one ,( !"hofie&d M* +onsensus !tatement of the ,"ademy of Nutrition and Dieteti"s/,meri"an !o"iety for Parentera& and 1ntera& Nutrition: +hara"teristi"s 9e"ommended for the 2dentifi"ation and Do"umentation of ,du&t Ma&nutrition (Undernutrition)* ' (arenter %nteral )utr 5%$5I6;(6):5<:-5>6*) to deter#ine i& Ms' #eets the de&inition o& a speci&ic cate.ory o& #alnutrition' *+plain your rationale' (8 points) Ms* D has e)perien"ed rapid( unintended weight &oss in the past ; months and is showing o'vious signs of tempora& and or'ita& wasting* 4er re"ent nutrition defi"it due to nausea( :

vomiting( and profuse diarrhea wou&d a&so point to an inade-uate energy intake* .o 'e "&assified as 'eing ma&nourished( a patient must meet at &east 5 of the ; re-uirements out&ined in the paper 'y Fhite et a&* ,t this point( Ms* D meets 6 of the ;( whi"h means that Ms* D wou&d meet the definition of ma&nutrition in the "onte)t of "hroni" disease* @* 9efer to Modu&e 2: the Nutrition +are Pro"ess( Nutrition Diagnosis and Medi"a& 9e"ord Do"umentation and your 2DN. 9eferen"e Manua&* 7ased on what you dis"overed in ear&ier -uestions( identi&y T42 of Ms* D3s #ost pro#inent nutrition-related pro$le#s within any of the domains (2N.,A1( +/2N2+,/ and/or 714,B209,/1NB290NM1N.,/ D0M,2N!) using the standard Nutrition ia.nostic Ter#inolo.y and INC,/ * the C2 * 5 from the 2DN. manua& for ea"h nutrition diagnosis you write* For each one" 6rite a co#plete nutrition dia.nostic state#ent in )*S &or#at 7pro$le#" etiolo.y" si.ns and sy#pto#s%" la$elin. each section 7)" *" and S% appropriately' ,* )*S 51! (8 points)

(P) Unintended weight &oss (2DN. +0D1N N+-6*5) re&ated to (1) side effe"ts e)perien"ed from ?2 ?B4D post-4!+.( as eviden"ed 'y (!) weight &oss of $5*6L in a ; month time period* 7* )*S 52! (8 points)

Ms* D wou&d meet the definition of ma&nutrition in the "onte)t of "hroni" disease* Ms* D wou&d meet the definition of ma&nutrition in the "onte)t of "hroni" disease*

2n the ne)t severa& -uestions( you wi&& 'e asked to deve&op a PN regimen for Ms* D* )lease use the &ollo6in. nu#$ers re&lectin. the .oal ener.y and protein le8els to do your calculations! 1N19?Y N11D! O 1900 total :cals P90.12N N11D! O ;9 .<day /U2D N11D! O 1900 #l<day N0.1: !ee J!amp&e +a&"u&ation for Parentera& eeding: 6-in-$ .ota& Nutrient ,dmi)tureC do"ument at the end of the Parentera& Nutrition notes to he&p you "omp&ete the "a&"u&ation* S124 (,, C(,C/,(TI2NS' $%* eter#ine non-protein :cals 'y su'tra"ting protein k"a&s from tota& k"a&s to 'e provided* (5 points) $8>> non-protein k"a&s

$$*

Split the non-protein :cals ;0<30 7C12<,ipid%' (8 points)

+ar'ohydrate k"a&s O PPP$%85 k"a&sPPP

/ipid k"a&s O PPPP88; k"a&sPPP

<

$5* ,* Calculate the .ra#s o& de+trose re-uired to provide the re-uired +40 k"a&s (from -uestion N $$)* (6 points)

0ra#s de+trose needed! PPPP6%; grams de)trosePPPPP 7* +41+A if this amount of de)trose e)"eeds the ma)imum +40 &oad of : mg/kg/min* Calculate the #a+i#u# a#ount o& car$ohydrate that should $e ad#inistered to this patient" $ased on the #a+i#u# o& 5 #.<:.<#in' (5 points) .he ma)imum amount of +40 that shou&d 'e administered 'ased on : mg/kg/min is 6<6 g de)trose*

Calculate the car$ohydrate load that you 6ill pro8ide to the patient" $ased upon the .ra#s de+trose needed 7calculated a$o8e%= (5 points) Fe are providing 8*$ mg/kg/min

Is the a#ount you 6ill $e pro8idin. in e+cess o& the #a+i#u#= (Yes or No) ($ point) No( the amount we wi&& 'e providing does not e)"eed the ma)imum of : mg/kg/min*

+*

eter#ine ho6 #any #l o& your ;0> de+trose stoc: solution 7 ;0% you need to .et the re?uired .ra#s o& de+trose you @ust calculated' (6 points)

#l o& ;0> de+trose stoc: solution needed! PPP86< m/PPPPPPP

>

$6* (' Calculate the .ra#s o& lipid re-uired to provide the re-uired &ipid k"a&s (from -uestion N $$)* (6 points)

0ra#s lipid needed! PPP8: grams &ipidsPPPPPP 7* +41+A if this amount of &ipid e)"eeds the ma)imum for &ipid administration*

4hat 6ould $e the #a+i#u# a#ount o& lipid that should $e ad#inistered to this patient= (5 points) .he ma)imum amount of &ipid that shou&d 'e administered 'ased on $ g/kg/day is :$*> g &ipids*

Is the a#ount you 6ill $e pro8idin. in e+cess o& this #a+i#u#= (Yes or No) ($ point) No( the amount of &ipid that we wi&& 'e administering is not in e)"ess of this ma)imum* +* eter#ine ho6 #any #l o& your 20> lipid stoc: solution 7,20% you need to .et the re?uired .ra#s o& lipid you @ust calculated in )art ( o& this ?uestion' (6 points)

#l o& 20> lipid stoc: solution needed! PPPP55: m/PPPPPPPP

$8*

eter#ine ho6 #any #l o& a 10> a#ino acid stoc: solution 7((10% you need to .et the re?uired .ra#s o& protein' (5 points)

#l o& 10> a#ino acid stoc: solution needed! PPPP<>% m/PPPPPP

$:*

eter#ine the &inal 8olu#e to $e ad#inistered' irst "a&"u&ate the minimum vo&ume re-uired to provide the re-uired k"a&s and protein 'y adding up the vo&umes of sto"k so&utions re-uired for ea"h ma"ronutrient (m& of D<%( /5%( ,,$%)* .hen add steri&e water as needed to meet the 'a&an"e of estimated f&uid needs* (: points) P86<PPPPm/ D<% D PP55:PPPm/ /5% DPP<>%PPPm/ ,,$% O PPP$885PPPPP tota& (Minimum vo&ume needed to a""ommodate +40( protein( and &ipid) ina& vo&ume re-uired to meet f&uid needs and to a""ommodate additives and e&e"tro&ytes: PP$>%%P m/ m/

$;*

eter#ine &inal concentration' (6 points) ,* L De)trose: PPPP$<LPPPPPPP

7*

L ,,: PPPPPP8*6LPPPPPP

+*

L /ipid: PPPPP5*:LPPPPPPP

$%

$<*

4rite out the &inal prescription and .oal rate o& ad#inistration' (: points) PP$>%%PPP m& D PP$<PPL ,,PP8*6PPL /PP5*:PPL with standard additives*

?oa& 9ate O PP<:PP m/ - hour* $>* 4rite out a plan &or pro.ression of the parentera& feeding to get to the goa& rate* 7e sure to state 6hat la$s you wi&& chec: $e&ore you initiate the regimen( and what you wi&& #onitor as you pro.ress the feeding towards your goa& rate* ,/!0 'e spe"ifi" if there are any particular issues or concerns you have a'out this patient as you initiate and progress her feeding* (; points)

$@*

?o to the 1!P1N we' site and &ook at the guide&ines for adu&t parentera& nutrition for nonsurgi"a& on"o&ogy* 4hat is the reco##endation &or .luta#ine in 1SCT patients= 4hat is the stren.th o& the e8idence 7i'e' 0-( *%= (6 points)

5%*

?o to the ,!P1N we' site and &ook at the guide&ine paper entit&ed J,!P1N +&ini"a& ?uide&ines: Nutrition !upport .herapy During ,du&t ,nti"an"er .reatment and in 4ematopoieti" +e&& .ransp&antationC( whi"h is pu'&ished in MP1N 5%%@I 66: 8<5* Fhat is ,!P1N3s re"ommendation on g&utamine in the 4!+. patient popu&ationG 4hat is the stren.th o& the e8idence 7i'e' 0-( *%" and ho6 does it co#pare to the *S)*N reco##endation= (6 points)

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