1. Patient Presentation By Kara LeClair

2. Patient Basics and Social Hx Age: 96 Sex: F Antrhotpometrics: Ht: 61”/155 cmWt: 144 lbs/65kg IBW: 105 +/-10%(115.5-94.5lbs) %IBW: 137% UBW: current %UBW: 100% BMI: 27.2 - overweight Social Hx: Pt. lives on her own in a senior housing apartment. Her son lives close by and her family is very involved in her.

3. Medical Hx Diagnosis: Colon Cancer Pt was admitted with UTI with sepsis, led to discovery of colon obstruction and distention PMHx: aortic stenosis, iron deficiency anemia, diverticulosis, elevated cholesterol, HTN, kidney stones, CHF

4. Treatments Past medical: Partial nephrectomy Left hemicolectomy – colon resectioning (3/31) CT scan: mass lesion at descending and sigmoidal colon junction Blood transfusion post op. (4/1) Nasogastric tube inserted twice post op – pulled out by pt. both times

5. MNT for Hemicolectomy & Colostomy Colon Cancer and Diverticulitis High-fiber diet 25 g/day Adequate hydration Colostomy Odorous stool formation may concerning for patients These foods include: legumes, onions, garlic, cabbage, eggs and fish. HTN, CHF DASH Diet – low sodium

6. Diet Order Current Diet Order: NPO Path of recovery: Pt. will progress to clear liquids, soft foods, low fiber diet and then gradually increase fiber intake to 25 g/day Before Surgery: 2 gram Na restriction

7. Pertinent Medications Current Medications: Lasix: diuretic – post op. Levaquin: antibiotic – UTI/sepsis treatment Lovenox: anticoagulant – post op. Flagyl: antibiotic IV – UTI/sepsis treatment Prior to admission pt. was taking only aspirin each day

8. Pertinent Labs Lasix use: Serum Potassium (N) Mg (N) Iron deficiency Anemia: MCH (L) RDW (H) RBC (L) HGB (L) HCT (L)

9. PES Pt. has inadequate energy intake related to colectomy on 4/1/15 as evidenced by no bowel movement since surgery.

10. Nutritional Education Pt. is currently NPO, which requires no education. Upon return to normal diet, focus emphasis on: Reduced sodium diet, such as added salts to food Increase fiber; may use supplement such as Metamucil Adequate energy intake Supplementation with Ensure Plus – normal intake only 50-75% Diet order once recovered: Increased fiber intake (at least 25 g/day), no added salt and supplement Ensure Plus TID

11. Caloric and Macro Nutrient Requirements Total Calories: 25 kcal/kg for patients >65= 1,625kcal Mifflin St. Jeor: (9.99*65)+(6.25*155)-(4.92*96)- 161= 1,929*1.2 (AF)*1.2 (IF) = 1,418kcal Protein Requirements: 1.5g protein g/kg/day = 98 grams/day Fluid Requirements: 30 mL x 65 kg = 1,950 mL/day (~65 oz)

12. Sample Menu Breakfast: 1 small banana 5.3 oz greek yogurt Snack: Ensure Plus, 8 oz Lunch ½ egg salad sandwhich on WW 1 apple, sliced Ensure Plus, 8 oz. 20 oz water throughout afternoon Dinner: 4 oz. grilled chicken, 1/3 cup WW pasta with lite tomato sauce, 1 cup steamed kale 12 oz water w/ Metamucil Evening: Ensure Plus, 8 oz. Total Calories: 2,140kcal Carbs: 1,211g Protein: 82g Fat: 44g Na: 1,000mg K: 1,560 mg Fluid: 62 oz

13. Intervention Food and/or Nutrient Delivery Whoever prepares the meals for the pt should be educated on a no added salt and increased fiber diet High in potassium and magnesium (if still on Lasix) Due to the patients past medical history of iron deficiency, blood loss (indicated by the blood transfusion) and lab values for RDW, HCT, HGB and RBC it may be beneficial to add an iron supplement. More blood work should be done after the blood transfusions are completed to see if this supplementation is warranted. Coordination of Nutrition Care This decision will be based on how well the patient recovers. Full recovery: she should be able to return to her senior housing. Limitations in recovery, or requires a more specialized diet: (remains on Lasix) her diet may require more attention, at which point her dietary needs must be addressed with whoever prepares her meals. If she is responsible for cooking for herself, there should be a plan set in place for someone to check on her regularly to make sure she is adhering to the diet and consuming enough potassium and magnesium.

14. Additional Treatment The family should seek advice from an oncologist and decide whether or not she will receive additional treatment for the colon cancer.

15. Monitor & Evaluate Food/Nutrition Related Outcomes: Pt. will progress to a normal diet with the return of bowel sounds, and consume 75% of each meal, along with three Ensure Plus supplements and one serving Metamucil or other fiber supplement as tolerated daily. Biochemical Data Outcomes: Increase MCH, RBC, HGB, HCT & decrease RDW by taking an iron supplement as directed. Other altered lab values are likely influenced by infection or stress of surgery and should return to normal limits as she recovers. Keep an eye on serum K & Mg with the use of Lasix. Anthropometric Outcomes: Pt. should aim to maintain her weight.

16. References Mahan, L. Kathleen., Sylvia Escott-Stump, Janice L. Raymond, and Marie V. Krause. Krause's Food & the Nutrition Care Process. St. Louis, MO: Elsevier/Saunders, 2012. Print. http:www.myfitnesspal.com Pronsky, Zaneta M., and Jeanne P. Crowe. Food Medication Interactions. Birchrunville, Penn.: Food-Medication Interactions, 2010. Print. *All images obtained from Google search engine

17. Questions