Question

Carmine is a 34-year-old mother of three young children. She was admitted to the hospital with multiple enterocutaneous fistulas 3 weeks ago, at which time she weighed 52 kg (116 lbs). She is 165 cm (5 ft 5 in) tall. Carmine has a history of recurrent cervical cancer for which she had a hysterectomy four months before admission. During chemotherapy that followed, she had regular bouts with nausea and anorexia. Surgery was performed again. Her fistulas continued to drain for 2 weeks postoperatively, during which she tolerated clear liquids only. An intravenous drip of 10% glucose and 45% normal saline was ordered to supplement fluids and kcal. This week she developed peritonitis and has had a fever with a maximum temperature of 39° C (102° F) over the past 24 hours. Her weight has dropped to 41 kg (90 lbs); drainage from the fistulas has become odorous. The patient was placed in isolation today and was advised by her physician that he intended to start her on total parenteral nutrition (TPN) and conduct some more tests to determine her progress.

Questions for Analysis

1. What types of nutrition assessment procedures would be used by the TPN team for planning Carmine's nutrition therapy? Explain the purpose of each.
2. Calculate Carmine's energy and protein needs, and account for increased needs.
3. Why did Carmine develop nausea and anorexia during chemotherapy? What are the implications of this for recovery?
4. Outline a plan for evaluating and controlling nausea and vomiting in patients undergoing chemotherapy.
5. What personal concerns would you expect Carmine to have? What resources would you use to help her obtain the personal and physical support she probably needs?

Answer 1

1. A - Anthropomorphic measurements like, •Height

•Weightof the client,

•Check BMI

As at present weight is 41kgs, and height is 165cm.

So, BMI is 15. 07 kg per meter square.

So she is extremely underweight we can notice.

Hence according to this TPN team can plan the high caloric diet to improve weight.

B- Biochemical or laboratory examination :

Electrolytes like calcium, potassium, chloride, sodium etc.

Hemoglobin estimation, and complete blood picture to know the WBC count and platelets etc.

C - clinical data :

She is on chemotherapy and having bouts of nausea and vomiting, having peritonitis and fever 102 degree foreign heat.

D - Dietary history :

She is on total parentral nutrition. Based on dietary history we can plan the needed nutrients to the client.

2. Total energy need = BMR X activity factor

Here BMR for women = 655 + (9.6 X weight in kg) + (1.8 x height in cm) – (4.7 x age in yrs)

BMR = 655 + (9.6 x 41) + (1.8 x 165) — (4.7 x 35) = 655 + 393.6 + 297 — 164.5 = 1181.1calories/day

Activity factor for sedentary lifestyle with no exercise is 1.2

So total energy need = 1.2 x 1181.1 = 1417.32

So catherine requires atleast 1417.32 calories per day.

Protein need

Lower limit for protein requirement = 0.8 x 41 = 32.8gm/day

Upper limit for protein requirement = 1.8 x 41 = 73.8gm/day

So we can say the protein requirement for Catherine ranges between 32.8 - 73.8gm/day.

The energy requirement has increased for Catherine because her body is recovering from a diseased conditions which requires for calorie and protein Consumption.

3. The advancement of sickness and anorexia amid chemotherapy are expected :

The chemotherapeutic medications trigger certain regions of mind.

It additionally can invigorate a few territories of the throat , stomach, small digestive tract, and intestine.The chemotherapeutic agents in the gastric or intestinal mucosa and cause incitement of vagal afferents that cooperate with the hindbrain of the focal sensory system , bringing about efferent vagal activity that prompts an emetic reaction

Chemo treatment expands dimensions of TNF and interleukin-1, bringing about anorexia and weight reduction.

Chemotherapy induced nausea and vomiting can be classified as

• Acute (occurring within 24 hours of therapy),
• Delayed(persisting for 6–7 days after therapy), or
• anticipatory (occurring prior to chemotherapy administration).

The occurance of vomiting is influenced by the emetogenic potential of the administered chemotherapy, patient variables.The emetogenic potential of the drugs depends on the chosen cytotoxic agent, the dose given, and the administration schedule.

Assess and contol Chemotherapy to the Patient-

i. Check for the level of lack of hydration

Give little measure of liquids for the duration of the day like water and squeeze.

If there should arise an occurrence of sevee spewing substitution of liquids by means of IV.

ii. Check the amount of food intake

Eat small and frequent meals
Eat before getting too hungry.
Eat dry foods such as dry cereal, toast immediately getting up from the bed.
Avoid heavy and high fat meals before chemotherapy.
Avoid caffeine and smoking.
Suck on hard candy, or ice during chemotherapy.

iii. Assess the tidiness of the environment:
Maintain a strategic distance from awful scents in the suroundings.

Rest by sitting up or leaning back with your head lifted atleast two hours in the wake of eating

iv. Check for the ways of Distraction during chemotheapy:

Relax and the keep the mind free during chemotherapy.
Listen to music, watch a funny film,get company of a good friend during chemotherapy.

4. A portion of the individual concerns which Catherine could hope to have are

To inspire all fundamental treatment to leave the afflictions the youngsters will be a primary worry for Catherine on the off chance that she is sick for a drawn out timeframe for doing and aiding her day by day exercises.

The most effective method to meet the expense of medicinal costs

Some of the resources which she can use to obtain the personal and physical support which she needs are-

• Counselling to support her emotionally to avoid mental stress.
• She can be connected with the support groups undergoing the necessary procedures to close her fistula.
• Meeting the metabolic needs and nutritional needs with the support of the healthcare team.
• Contamination control rehearses pursued by social insurance group to maintain a strategic distance from disease.