Download Oncology_SLCaseForm

OHSU Dietetic Internship
Eva Yuen
Nutn 512
Spring Quarter
Standardized Language: Case Study Exercise
Please complete this form for the NUTN 512 case studies (Liver, Oncology and
Dysphagia) and return by the dates noted on the syllabus.
1. Record pertinent information in the categories below concisely. Information
for the assessment section can be obtained from each case study.
2. Use ADA’s standardized language to complete the Diagnosis, Intervention
and Monitoring and Evaluation sections.
Assessment:
54 yr old female , admitted with a lesion of the distal esophagus related to squamous
cell carcinoma.
Pertinent previous medical history (PMHx):
Patient is in good health up until 6 weeks ago with difficulty in swallowing.
Anthropometric data (incl recent wt change, if any)
Weight: 155 lbs (70.45kg) Height: 5’6” (167.64cm) BMI: 25
IBW: 130 lbs (59.1kg)
%IBW: 119%
UBW: 165 lbs (75kg)
Weight change: ↓10 lbs involuntary weight loss
%UBW: 93.9%
Diet order, previous diet if any, knowledge base
Diet history: Breakfast – 2 cups of coffee, lightly sweetened / Oatmeal (occasionally)
Lunch and Dinner – 2 cups of broth-based soups /stews
Small servings of canned vegetables and fruits
Water /diet soda
Food intolerance/allergy: Pt doesn’t drink milk
Others: Pt has been avoiding dry foods such as breads and crackers due to swallowing
difficulty
Nutrition-related meds (include OTC, vitamins, herbs):
No medications regularly
Chemotherapy/radiation regimen ordered
Pertinent labs (indicate normal range for your lab)
Albumin= 3.1 g/dL
↓ (3.5-5.0 g/dL)
Pertinent Input/Output, CBGs, etc: N/A
Physical findings (edema, pallor, muscle wasting, etc)
A lesion of the distal esophagus, dysphagia
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OHSU Dietetic Internship
Eva Yuen
Nutn 512
Spring Quarter
Diagnosis:
P: _Inadequate protein-energy intake
E:
swallowing difficulty_
_________________
___as related to
as evidenced by
S/S:__ 10 pounds involuntary weight loss in 6 weeks and low albumin level.
Intervention:
Nutrition Prescription: Patient’s estimated nutrition needs are 2110-2470 kcals (30-35kcal/kg)
and 85-106g (1.2-1.5g/kg) protein per day with small frequent meals and modified food
consistency.
Goal—Short term: Increase food intake to meet nutrition needs. Identify best-tolerated
foods. Encourage fluids and small frequent meals. Avoid weight loss.
Goal—Long term: Maintain optimal body weight. Reduce treatment side effects. Decrease
risk of infection. Improve quality of life.
Intervention(s):
ND-1.2
Modify distribution, type, or amount of food and nutrients within meals or at
specificed time
ND-1.3
Specific foods/beverages or groups
ND-3.1.4 Modified food
RC-1.1
Team meeting
RC-1.3
Collaboration/referral to other providers: Speech-language pathologist
E-1.1
Purpose of the nutrition education
E-1.2
Priority modifications
Monitoring and Evaluation:
Nutrition Care Outcome(s):
Outcomes indicatory:
BE-2.1.1 Meal/snack planning ability
FI-1.1.1 Total energy intake
FI-5.2.1 Total protein
S-1.1.4 Weight/weight change
Criteria:
- Ability to plan meal/snack to meet
nutrition needs
- Energy intake will meet Nutr Rx goals
- Protein intake will meet Nutr Rx goals
- Weight will stabilize/weight gain
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OHSU Dietetic Internship
Eva Yuen
Nutn 512
Spring Quarter
NOTE: An initial note may only list the nutrition care outcome indicators that will
be monitored for that patient/client; it should indicate where patient is at base-line
with respect to the outcome when that is known. Follow-up notes will include some
measure and evaluation of the outcomes that were identified.
Example: Initial note “Monitoring and Evaluation: Nutrition Care Outcome—total fat
intake”. (Could say “total fat intake 200% of recommended level” if you know that.)
Follow-up note “Monitoring and Evaluation: Nutrition Care Outcome—Based on 3day food diary, total fat intake now about 150% of recommended level.”
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