FCFN 447

Case Study
Enteral Feeding and Esophageal Cancer
ANNA BEYNON

CASE TWO
CN is a 50yr old white male inpatient at a university hospital. Reports 25lb weight loss since recent dx
esophageal cancer (within 6mos). Exhibits dysphagia and loss of appetite. CN is post-esophagectomy
with jejunostomy tube placement. Chemotherapy and radiation therapy are planned. During this
hospitalization, a swallowing study was conducted to r/o a postoperative leak and to assess whether it
was safe for CN to resume eating and drinking. He passed swallowing test, a liquid diet was initiated,
and he has progressed to a regular diet. The dysphagia and appetite concerns have kept him from
regaining much weight.

Medical Hx
CN has no significant past medical history.

Medications
No medications.

Current Treatments
Chemotherapy and Radiation Therapy to be initiated.

Diet History/Vitamin and Mineral Supplementation

Reports limiting intake to juices, broth, and tea over past month. Attempting to eat while in the hospital,
but dietary intake remains at 25-50% according to chart.

Social History
Lives alone. Denies drug and alcohol use. CN smoked two packs of cigarettes per day for 30 years (40
cigarettes per day), but quit two years ago. CN’s dysphagia has worsened over past 6 weeks, and
appetite became poor.

Review of Systems
General: Fatigue, weight loss
GI: poor appetite, dysphagia
Sx of muscle wasting, though no earlier measurements were taken

Physical Examination
Height: 5’11” (180cm)
Weight: 130lb (59kg)
UBW 70kg (155lbs)
Current BMI 18kg/m2
Lost 25 lbs over the last six months
Loss of muscle mass (per MD report)
MD Exam: Cachectic male in no acute distress
Laboratory Data Desired Range
Hgb 13.5g/dl 13.5-17.5g/dl
Hct 40% 40-52%
Albumin 3.1 g/dl 3.2-5 g/dl
BUN 13mg/dl 10-20mg/dl
Potassium 3.6mmol/L 3.5-5.0mmol/L
Sodium 136mmol/L 133-143mmol/L

Follow-up Description
CN was discharged from the hospital when he was able to eat an adequate oral diet. His jejunostomy
tube was not removed because in 4 weeks he would be receiving chemo and RT that could adversely
affect his oral intake. CN was instructed to flush his jejunostomy tube daily with 60cc water to keep it
patent (open).

Four weeks later, CN began receiving chemo and RT. Within 2 weeks of the first treatment, CN
developed severe odynophagia (painful swallowing). As a result, his oral intake greatly diminished.
Based on a 24 hour recall and usual intake over the past week, CN reported consuming ½ cup of flavored
gelatin and 6oz of applesauce daily, which totals about 200 calories per day with no significant amount
of protein, vitamins, or minerals.

Critical Questions:
ASSESSMENT
1. After reviewing CN’s chart, list your top three concerns (most immediate nutrition problems).
List secondary concerns (items that will need addressed in the future, but aren’t critical at this
time).
My top three concerns are:
Odynophagia (Primary)
Her dietary intake (Secondary)
25 lb weight loss and inability to regain weight (Secondary)

2. Review CN’s cancer treatment regimen. What are the significant side effects of the treatment(s)
she is undergoing?
One concern for individuals undergoing chemotherapy and/or radiation is dehydration,
deficiencies in vitamins and minerals is common, N/V is most common side effect and mucositis
affects 40-70% of all chemotherapy/radiation patients.

3. Please use the Mifflin St. Jeor predictive equation and quick calculation method to determine his
total kcal needs (SHOW WORK):
-Mifflin St. Jeor (male)
10*wt(kg) + 6.25*Ht(cm) - 5*Age(yrs) + 5 = resting energy expenditure
Multiply by 1.3 Activity Factor (Sedentary)
10*59kg + 6.25*180cm – 5*50 + 5 =
590 + 1125 – 250 + 5 =
1715 – 255 = 1460

1460*1.3 = 1898

-Briefly compare this to the calorie estimations for weight gain (35kcal/kg/day).
 According to the calorie estimations for weight gain, CN should be consuming roughly 2,065
kcals, however, with the Mifflin St. Jeor equation she is only required 1,460 kcals. She is not
consuming enough calories to help gain the 25lbs she lost back if going by the Mifflin St. Jeor
equation estimations.

NUTRITION DIAGNOSIS
4. Write a PES statement that would be appropriate for CN (addressing the most critical issue first).
Please use the Nutrition Diagnostic Terminology handout to determine the appropriate
diagnosis (please use the full diagnosis, not the code).
CN has inadequate oral intakes and inadequate protein-energy intakes related to odynophagia
as evidence by weight loss of 25 pounds in 6 months.

INTERVENTION
5. Calculate an enteral feeding prescription for CN. Base the tube feeding prescription on the
estimated kcals/kg (for weight gain), and using the product Ensure High Protein. Please
determine the total kcals, protein and fluid needs, and establish how much of the formula
should be offered in a QiD bolus feeding schedule.
Total kcals: 2,065 kcals
Protein: 86 g / 344.85 kcals
Fluid: 712 mL Free Water
QiD: 258 mL

6. In addition to your primary Nutrition Diagnosis, are there additional matters you would like to
discuss with CN, or provide nutrition education for, in subsequent counseling sessions? Please
list.
I would want to have an education session with CN discussing food sources of protein, vitamins
and minerals. Educating CN on shakes, beverages and eventually foods that have proper
nutritional value for her condition would be a crucial step in helping her gain back weight and
muscle strength, or at the very least, prevent her from losing more weight.

MONITORING & EVALUATION

7. What will you monitor to determine if the Nutrition Intervention was a success? Based on your
Nutrition Diagnosis, develop a step-wise intervention for CN. Determine what methods you will
use (Education? Counseling? Coordination of Nutrition Care? Diet Change?). Include three topics
you would address with CN, and why.
I would monitor CN’s diet history and chart while in the hospital to see if she has increased from
the original 25-50% to indicate any alleviation of odynophagia and increase in caloric intake
either by mouth or enteral feeding. I would also monitor her weight and BMI to see if there was
any increase. My intervention for CN would consist of a counseling session followed by an
educational session with a diet change. My hope for CN would be for her to consume more
nutrient dense foods, containing more protein, vitamins and minerals. I would also emphasize
the importance of hydration, as well as ways to cope with N/V with her upcoming radiation and
chemotherapy treatments.

8. Note: These are generally based on the S/S of the PES statement. Are there any labs you would
like to continue to monitor? I would monitor all of her laboratory data, all of her labs were in the
green, with the exception of albumin, however they were all on the low end of the green and
had potential to drop below desired levels.