Abstract
This case study documents the nutritional diagnosis and intervention process implemented in a hospital setting for a malnourished patient undergoing chemotherapy for a chronic illness. The patient, receiving chemotherapy for colorectal cancer that had metastasized to the liver, presented with significant malnutrition and a 17% weight loss over three months. This weight loss was attributed to chemotherapy side effects such as stomatitis, nausea, and vomiting. Utilizing the nutrition care process, two rounds of nutritional screening and intervention were conducted. These interventions led to an increase in oral intake from 28% to 62% of the recommended daily intake. The patient required ongoing monitoring and outpatient care post-discharge. The study suggests that proactive patient education and a structured dietary regimen addressing chemotherapy side effects, initiated after the first chemotherapy cycle, could potentially mitigate ingestion problems like stomatitis and prevent subsequent weight loss during further cycles. Therefore, comprehensive nutrition management education and continuous monitoring are crucial for chemotherapy patients to prevent malnutrition.
Keywords: Malnutrition, Nutritional Intervention, Nutrition Care Process, Chemotherapy, Cancer, Case Study, Stomatitis, Weight Loss
Introduction
Malnutrition is a prevalent concern among cancer patients undergoing treatment, often stemming from appetite loss, indigestion, malabsorption, and metabolic disturbances [1]. Chemotherapy, a common cancer treatment, frequently induces side effects such as anemia, anorexia, dysgeusia, altered food temperature sensitivity, constipation, diarrhea, dysphagia, xerostomia, fatigue, and early satiety [2]. These side effects can significantly impair food intake and lead to substantial, detrimental weight loss [3]. Effective nutritional intervention is therefore paramount in managing these challenges.
The primary aim of nutritional intervention for these patients [4] is to enhance their nutritional status. This is achieved by alleviating treatment-related side effects, delivering personalized patient care, and improving dietary intake while respecting individual food preferences. A progressive approach to intervention is crucial. Improved nutritional status is directly linked to better treatment outcomes and an enhanced quality of life for patients [3]. The principles and practices outlined in resources like “Nutrition and Diagnosis-Related Care, 6th edition,” provide a comprehensive framework for addressing these complex nutritional needs in clinical settings.
A cornerstone of nutritional intervention involves recommending frequent, small meals, typically 5-6 times daily. This strategy aims to maximize overall intake, especially given the common occurrence of appetite loss due to metabolic changes and chemotherapy. When oral intake falls below 60% of the recommended daily intake, alternative feeding methods such as tube feeding or intravenous alimentation may be necessary [5]. However, oral intake, with diets tailored to each patient’s condition, remains the preferred method whenever feasible. Dietary adjustments, including offering hot or cold foods and beverages based on patient preference and tolerance, are essential. Modifications are continuously made in response to the patient’s evolving condition. In cases requiring a low-bacteria diet, appropriate food choices are provided, and patients receive thorough education on relevant dietary practices.
This case study aims to meticulously document the nutritional diagnosis and intervention process applied to a malnourished cancer patient undergoing chemotherapy at a hospital. The patient was identified as being at risk of malnutrition through an early nutritional assessment program upon admission for generalized weakness. This study received ethical approval from the Institutional Review Board at Kyung Hee University Hospital at Gangdong (KHNMC IRB 2013-116).
Case
On October 21, 2013, a 61-year-old male patient was admitted to the gastroenterology ward. A comprehensive nutritional assessment was conducted, encompassing medical history, physical measurements, biochemical data, medical treatments, nutritional physical examination findings, and dietary history. The primary presenting symptom was generalized weakness. The patient’s medical history included diabetes mellitus and hypertension, both diagnosed 10 years prior, and rectal cancer diagnosed 3 years prior. For the rectal cancer, the patient had undergone an ileostomy on November 14, 2011, and received leucovorin plus fluorouracil (LV5FU2) chemotherapy (preoperative #1 and postoperative #8). Subsequently, an ileostomy repair was performed on December 3, 2012, followed by a liver wedge resection on July 18, 2013, to address liver S4 metastasis detected during follow-up. The patient then received four cycles of chemotherapy (FLOFOX4 regimen: oxaliplatin, folinic acid, and 5-fluorouracil) from September 2 to October 14, 2013. Current medications included Lantus 10 U/day, Apidra 6 U three times daily, and Nutriflex lipid peri [+ Humulin-R (regular insulin) 15 U] every other day. Chemotherapy was temporarily discontinued due to the patient’s general weakness.
The initial nutritional screening occurred on October 22, 2013. Upon hospital admission (October 21, 2013), physical measurements were recorded: height 167 cm, weight 53.2 kg, ideal body weight (IBW) 61.4 kg, %IBW 86.6%, body mass index (BMI) 19.1 kg/m2, usual weight 64.8 kg (July 18, 2013), and a weight loss of 11.6 kg (17.9%) over the preceding three months. Admission laboratory findings included: total protein/albumin 5.6/3.2 g/dL, hemoglobin/hematocrit (Hgb/Hct) 8.4 g/dL/25.4%, total lymphocyte count (TLC) 741.2 cells/mm3, cholesterol 162 mg/dL, blood urea nitrogen/creatinine (BUN/Cr) 20/1.0 mg/dL, Ca/P 8.3/2.3 mg/dL, Na/K/Cl 132/4.2/98 mEq/L, C-reactive protein 6.28 mg/dL, hemoglobin A1c 9.7%, and casual glucose 470 mg/dL.
Nutritional and physical examination revealed stomatitis, nausea, and vomiting as chemotherapy side effects. Blood pressure was 142/83 mmHg. Dietary history revealed appetite loss post-chemotherapy and a lack of prior nutrition education for cancer patients, attributed to patient fatigue. In the week following the fourth chemotherapy cycle, the patient’s consumption included six glasses of cola daily (480 kcal/day; 120 g sugar) to alleviate stomatitis, nausea, and vomiting. Hospital-provided soft foods, particularly gruel, were not tolerated due to pain and vomiting. Intravenous alimentation (Nutriflex lipid peri EOD; energy 465 kcal; C:P:F ratio 34.4:17.2:48.4; carbohydrate 40 g; protein 20 g; fat 25 g) was being administered. No liquid or solid nutritional supplements or bioactive substances were being consumed. The patient remained bedridden throughout the day.
The Patient-Generated Subjective Global Assessment (PG-SGA) [6] score was 15, indicating a need for symptom management and focused nutritional intervention. Estimated nutritional requirements were 1600-1860 kcal of energy (based on baseline weight of 53.2 kg and a need of 30-35 kcal/kg) and 64-85 g of protein (based on baseline weight of 53.2 kg and a need of 1.2-1.6 g/kg).
Two nutritional diagnoses were established: first, malnutrition due to reduced food intake related to chemotherapy side effects (stomatitis, nausea, vomiting) and inadequate nutrition knowledge regarding food types and quantities. Evidence supporting this diagnosis included a 17.9% weight loss in the past three months and consumption of only 28% of required nutrients in the week post-chemotherapy cycle four. Second, a knowledge deficit regarding appropriate foods and nutrients, potentially stemming from fear of food intake, manifested as food refusal and reliance on cola post-chemotherapy.
Nutritional interventions for the first diagnosis included advising the medical team to transition the patient to a diabetic thin rice gruel diet (Figure 1) (1,700 kcal and 72 g protein) and to adjust intravenous alimentation based on oral intake, aiming for ≥ 30% of nutritional needs to be met by hospital food and intravenous support. Hospital-provided food was soft and non-irradiated to accommodate stomatitis. Close monitoring post-dietary changes was deemed necessary. For the second diagnosis, the intervention involved counseling the patient on the importance of consuming a variety of foods and the hospital diet (diabetic thin rice gruel), while considering patient preferences and lactose intolerance. This intervention aimed to discontinue cola consumption, which could exacerbate nausea, and encourage intake of hospital-provided meals.
Figure 1.
Alt text: Diabetic thin rice gruel diet providing 1700 kcal, a meal plan designed for patients with diabetes, showcasing a soft and easily digestible food option for nutritional support.
A 1,700 kcal thin rice gruel diet for diabetic patients.
The second nutritional screening was conducted on October 24, 2013. Physical measurements remained unchanged. Biochemical data revealed: total protein/albumin 5.1/3.1 g/dL, Hgb/Hct 8.5 g/dL/25.7%, TLC 712 cells/mm3, cholesterol 135 mg/dL, BUN/Cr 19/1.0 mg/dL, Ca/P 7.8/1.6 mg/dL, Na/K/Cl 138/50/107 mEq/L. Blood glucose levels (fasting, postprandial 2-hour glucose #3) were: 177/208/363/309 mg/dL (10/22), 270/206/206/120 mg/dL (10/23), and 126/133/260/246 mg/dL (10/24). Nutritional physical examination continued to show gastrointestinal symptoms, including nausea and vomiting triggered by certain foods. For instance, orange juice induced vomiting, while apple juice was well-tolerated. Vital signs were stable at 135/80 mmHg. Dietary counseling had been provided regarding diabetic thin rice gruels, non-irritating foods, and nutrient supplement drinks.
The patient’s dietary intake now consisted of the hospital-provided diet: 20% of rice gruel, 50% of steamed eggs and nutritious beverages, and 100% of soup and apple juice (totaling 1,050 kcal; C:P:F ratio 56.0:14.4:29.6; carbohydrate 147 g; protein 37.2 g; fat 34.5 g), along with intravenous alimentation (Hepasol inj 500 mL/day; 200 kcal, 50 g protein). Following the initial screening, the patient had attempted various foods and started using a wheelchair for mobility. Nutritional requirements remained consistent with the first screening. Nutritional monitoring indicated partial achievement of the initial nutritional intervention goals. Hospital food consumption had increased to 62% of overall intake, and intravenous alimentation had been changed from Nutriflex lipid peri EOD to Hepasol/day. Following the second intervention, cola consumption ceased, and the patient began consuming a more diverse range of hospital-provided foods, indicating goal attainment for this aspect of the intervention.
After the second screening, two new nutritional diagnoses were identified: first, excessive protein supplementation, as intravenous alimentation was providing additional protein beyond oral intake, resulting in 125% of required protein consumption. Second, a persistent knowledge deficit regarding food and nutrition, attributed to the lack of education concerning chemotherapy and food preparation. Nutritional interventions for the first diagnosis involved advising the medical team to discontinue protein administration via intravenous alimentation. For the second diagnosis, the medical team was advised to educate the patient on appropriate food choices and preparation methods to manage chemotherapy side effects, aligning with established guidelines in resources such as “Nutrition and Diagnosis-Related Care, 6th edition”. The overall goal of intervention shifted to achieving energy and protein intake ≥ 70% of requirements and maintaining or increasing body weight. Continuous monitoring and appropriate outpatient care post-discharge were emphasized.
Discussion
This case highlights a patient who experienced significant, unintentional weight loss and malnutrition due to chemotherapy side effects, specifically stomatitis, nausea, and vomiting, leading to poor oral intake. Nutritional interventions, guided by the nutrition care process, successfully increased the patient’s food intake, with further improvements anticipated through ongoing care (Figure 2). This aligns with previous research demonstrating the effectiveness of individualized nutritional education in enhancing caloric and protein intake in cancer patients [7,8]. This case study suggests that proactive education on chemotherapy side effects and food preparation, delivered before and after colon cancer surgery, could have potentially mitigated ingestion problems caused by stomatitis and prevented weight loss following the second chemotherapy cycle. The principles of timely and effective nutritional support are extensively discussed in “Nutrition and Diagnosis-Related Care, 6th edition,” underscoring the importance of early intervention.
Figure 2.
Alt text: Patient’s nutritional care flow chart illustrating the progression of nutritional diagnosis, intervention, and monitoring, demonstrating the cyclical nature of the nutrition care process in clinical practice.
Patient’s flow chart.
Moving forward, it is imperative that all patients undergoing chemotherapy receive comprehensive education on strategies to improve treatment response and undergo continuous monitoring throughout their treatment journey. In this specific case, it is regrettable that despite repeated diagnoses of malnutrition during hospital readmissions during the second chemotherapy cycle, active malnutrition management was not initiated earlier. This case underscores the critical need for consistent and proactive nutritional care for chemotherapy patients, as emphasized in contemporary nutritional guidelines and resources such as “Nutrition and Diagnosis-Related Care, 6th edition.”
Footnotes
No conflict of interests were declared by any of the authors.
References
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