�  E.W. - 83 YOF

�  Caucasian, Catholic, widowed, resides in Queens, lives alone (for 33 years), her 2 nieces are main people involved w/ her care

�  Retired secretary (12 years ago), walked 13 blocks to and from her church to volunteer everyday after retirement up until her illness.

�  Smoked 3 cigarettes/day for 20 years (quit many years ago), has alcohol 1x/month

�  Admission: 3/21/12

�  Admitting DX: Ampullary CA

�  Cooks all of her own meals

�  Sample day (before illness): �  Breakfast- oatmeal, blueberry muffin, Ensure �  AM Snack- Ensure �  Lunch: Turkey sandwich on rye, potato salad, Pepsi, Ensure �  PM Snack: Ensure �  Dinner: rice pudding, jello, Pepsi, Ensure

�  Meds/Vits: amlodipine (antihypertensive), MVI

�  No Food Allergies

�  No significant past medical problems �  Mild HTN- treated years ago and stopped medication

�  Prior to dx, no previous hospitalizations

�  Jan 2012: First sign of symptoms �  1/14: Presents w/jaundice, excoriation from severe pruritus,

dysguesia, B/L LE weeping edema, tea-colored urine and clay-colored stools �  Abdominal CAT scan è suggested periampullary neoplasm

�  1/16: EUS è ampullary mass w/ lesion, dilatation of CBD and pancreatic duct (c/w cholestasis)

�  1/18: ERCP è Ampullary CA confirmed, balloon stent was placed in bile duct SURGERY PLANNED

�  Surgery planned for 3/21/12

�  Admitting symptoms: jaundice subsided, 30# wt loss, nausea, LE vascular lesions, NPO for surgery

*Staging Laparoscopy w/ US, Whipple, Omenectomy, and J-tube insertion

�  Surgical Pathology RESULTS:

*No luminal stones in gallbladder

*No mass lesions identified in omentum

*No malignancy in liver

*No malignancy in surrounding lymph nodes

T2 N0

M0

*T2: Tumor limited to the pancreas, >2cm in greatest dimension *N0: No regional lymph node metastasis

*M0: No distant metastasis

�  3/22

�  NG tube placed to suction serosanguineous fluid �  Epidural given for pain �  Leg dressings changed daily �  Meds given: heparin, metoprolol, protonix, narcan

�  3/23

�  Low urine output noted è IV LR @100cc/hr �  *NUTRITION ASSESSMENT

NCP

Assessment

Diagnosis

Intervention

Monitoring/Evaluation

�  E.W. assessed on 3/23/12, POD#2

�  Anthropometrics: �  Ht: 5’2” �  Wt: 132# �  UBW (Jan): 165# � %UBW: 80% �  IBW: 110#±10% � %IBW: 120% (109% UIBW) �  BMI: 24.2 (normal)

�  Current problems: �  Vascular lesions on both legs �  Trace edema �  Nausea �  Oliguria �  Nasogastric tube for suctioning �  Confused

20% wt loss in 2

months!

�  Nutrient Requirements:

�  1500-1800 kcal (25-30 kcal/kg) �  72-90 gm protein (1.2-1.5 gm/kg) �  40-60 gm fat �  213-225 gm carbohydrate �  ~1500 ml H20 (25ml/kg) *Based on her actual body weight

�  Current diet order per MD: �  NPO �  Jevity 1.5 @ 20cc/hr via J-tube (goal rate of 40cc/hr)

�  Providing 720kcal, 31gm pro, 365 cc H20

20%

53%

27% PRO

CHO

FAT

PES Guess???

NCP

Assessment

Diagnosis

Intervention

Monitoring/Evaluation

�  PES Statement

Inadequate oral intake (NI-2.1) related to physiological causes increasing nutrient needs due to dx of Ampullary CA as evidenced by 30# wt loss, nausea, emesis, dysguesia, decreased appetite, and NPO status 2° Whipple procedure.

NCP

Assessment

Diagnosis

Intervention

Monitoring/Evaluation

GOALS PLANS 1. Tolerate TF at a goal rate of 50cc/hr 2. Maintain wt within +- 1-2# current BW; No further wt loss 3. Increase albumin to >3.5mg/dL within 2 weeks 4. Maintain adequate hydration, >1500cc fluid daily 5. Glucose <150mg/dL while receiving enteral nutrition

-Increase TF rate by 10cc/day until a goal rate of 50cc/hr is reached -Monitor residuals; stop TF if >250cc -Offer Ensure qd and encourage intake of protein-rich foods supplements once p.o. initiated -Recommend 250cc H20 flushes TID (once IVF dc’d)   -FS q6º to monitor blood glucose levels -If BG >180mg/dL, consult Endocrinology and provide insulin coverage