Jewett, Webb

Case Study
Medical Nutrition Therapy for Patient with Esophageal Cancer

Introduction
Approximately 18,000 Americans are diagnosed with esophageal
cancer each year. Esophageal adenocarcinomas (EACs) comprise
approximately 12,000 of these cases, and squamous cell carcinomas
(SCC) comprise the other 6,000 cases. SCC is considered a cancer of
alcohol and tobacco use, while EAC is considered a cancer of GERD,
Barretts esophagus, and obesity.1 Unfortunately, those diagnosed with
esophageal cancer have a relatively low survival rate compared with
individuals diagnosed with other treatable carcinomas.2 Considering
the fact that approximately 45.3 million American adults consume
tobacco and 35.7 million American adults are classified as obese,
contributing to risk for the development of EACs, esophageal cancer is
of major concern to the American population.3 4
The primary function of the esophagus is to aid in the movement
of food from the pharynx to the stomach. The upper esophagus is
composed of striated muscle which allows for voluntary control of
swallowing, while the lower esophagus consists of smooth muscle for
involuntary movement of food. The esophagus also houses two
sphincters, the upper esophageal sphincter and lower esophageal
sphincter that help regulate the flow of food. The upper esophageal
sphincter controls food migration from the pharynx into the esophagus
and is responsible for preventing the entrance of food into the trachea.
The lower esophageal sphincter helps to control backflow of gastric
juices from the stomach into the esophagus. The diaphragm, a smooth
muscle that separates the esophagus and stomach, helps position the
esophagus in an upright position and allows for full closure of the lower
esophageal sphincter. The esophagus does not have a protective layer
of mucus, as is found in the stomach, and is thus more prone to
damage and erosion from gastric juices.
Etiology of the Disease
Stage IIB (T1, N1, M0) esophageal adenocarcinoma (EAC) is a
node-positive malignant tumor of the esophagus that has not yet
metastasized to additional body tissues. Factors that contribute to the
development of EAC include gastroesophageal reflux disease (GERD),
use of proton pump inhibitors (PPI), obesity, cigarette smoking,
presence of Barretts esophagus (BE) and male gender. As many as
34% of EAC cases are preceded by BE.5 However, a significant
proportion of cases do not involve pre-dating symptoms of GERD or BE.

Furthermore, there are independent risk factors affecting risk of EAC.

Risk factors include: chronic cough, diabetes, and age.
Typical symptoms and lab values used to diagnose, assess,
monitor disease
Diagnosis of EAC follows identification of typical symptoms followed
by an evaluation of lab values and tissue samples. Symptoms similar to
those of GERD and laryngopharyngeal reflux, such as burning
sensation after meals, heartburn, increased salivation, esophageal
spasm asthma, and hoarseness, may be used to screen for EAC. Laterstage symptoms may include pain, obstruction, and dysphagia. 6
Complete blood count and occult blood may be taken in order to detect
possible internal bleeding from EAC.
Currently there are few researched and agreed upon diagnostic
markers for EAC, therefore diagnosis primarily relies on evaluation of
biopsy to determine cancer.7 However, because early diagnosis is vital
to the survival of the patient, several prognostic and diagnostic
markers are under examination. Tanzer et al. suggest strict monitoring
upon the diagnosis of BE by tissue biopsy and biomarkers. Tanzer and
colleagues compiled several possible biomarkers for prediction,
prognosis, diagnosis, and progression of BE and EAC. CDKN2A allelic
loss and 9 gene methylation panel offer potential biomarkers for
prediction, while amplification of 7q21 *CDK and 12q113 (CDK4),
telomere length, 7 gene methylation panel, NELL1 hypermethylation,
and methylation of DAPK and APC offer possible biomarkers for
determining prognosis.
To diagnose EAC, the physician may use AKAP12 promoter
hypermethylation, reprimo methylation, and TAC1 promoter
hypermethylation.7 Progression may be monitored using aneuploidy
and tetraploidy, copy number changes in chromosome 7 and/or 17,
leucocyte telomere length, EDFR overexpression, HPP1
hypermethylation, 8 gene methylation panel, 17 p LOH and 9p LOH,
low grade dysplasia, abnormal DNA ploidy, AOL, p53 LOH, clone size,
and clonal diversity. Other research includes using the relatively
nonevasive and inexpensive collection of salivary miRNA. Xie et. al
have found supernatant and whole salivary miRNA types miR-10b*,
miR144, and miR-451 to be clinically significant indicators of
esophageal cancer in high risk patients.8
However, until research indicates accurate and universal
markers, physicians will continue to use x-ray computed tomography
(CT scan), positron emission tomography (PET scan), and endoscopic
ultrasounds to determine the presence and progression of a cancerous
tumor.1 A CT scan requires a patient to swallow contrast materials such
as dye. Contrast materials are also injected into a blood vessel of the
patients hand or arm. The contrast materials provide a means to

visualize blood flow and identify abnormal areas of growth. A PET scan
includes an injection of a small amount of radioactive sugar into the
patients bloodstream. Because abnormal cells tend to utilize sugar
faster, the abnormal growths look different than healthy cells in the
body. An endoscopic ultrasound uses high-energy ultra-sound waves
to determine how far the cancer has penetrated into esophageal
tissue.
Symptoms affected by or affecting nutrition
As previously mentioned, esophageal carcinomas present
difficulties such as dysphagia and GERD. Dysphagia is defined as
swallowing difficulty and may be caused by a variety of factors,
including: obstruction, inflammation, upper esophageal sphincter
dysfunction, disorders of the skeletomuscular system, and motility
disorders. Altogether, disorders leading to dysphagia generally cause a
decreased ability to maintain adequate food intake.
GERD is marked by the reflux of acidic stomach contents
backwards into the esophagus. Symptoms that may result from GERD
include a burning sensation after meals, heartburn, increased
salivation, esophageal spasm, asthma, belching and hoarseness. If
GERD progresses to erosive GERD, symptoms may become more
severe, resulting in esophageal inflammation and possibly dysphagia.
The pathophysiology behind GERD development may include
scleroderma, diseases that increase acid secretion, pregnancy,
pressure-lowering hormonal fluxes, and reduced lower esophageal
sphincter pressure resulting from hiatal hernia. GERD is frequently
treated with medications. GERD medications include histamine
blockers like Pepcid Complete , proton pump inhibitors like Nexium
or Prevacid, antacids like Alka Setlzer and TUMS and prokinetics
like REGLAN often cause nutritional complications include histamine
blockers like Pepcid Complete , proton pump inhibitors like Nexium
or Prevacid, antacids like Alka Setlzer and TUMS and
prokinetics like REGLAN . These medications often cause nutritional
complications related to a decrease in stomach acidity as well as a
decrease in gastric emptying time, resulting in potential malabsorption
of nutrients like iron and B12.
Symptoms associated with treatment:
Nutritional implications of EAC first stem from the carcinoma
itself. An esophageal carcinoma may present symptoms that reduce
adequate nutrient intake and utilization in cancer patients. Such
symptoms include: esophageal obstruction, dysphagia, pain, dyspnea,
nausea, vomiting, fatigue, weakness, insomnia, anorexia, constipation,
confusion, anxiety, and depression.9 Furthermore, presence of a

carcinoma often results in rapid weight loss, increased energy needs,

and increased potential for drug therapy.10 Additionally, many cancer
patients suffer from a multifactorial syndrome that is often
accompanied by muscle atrophy, with or without loss of fat mass,
associated with increased muscle breakdown, anorexia, insulin
resistance, and inflammation. This complex syndrome, also known as
cachexia, is generally described as the non-specific ill feeling many
cancer patients experience. Cachexia results in unintentional weight
loss and necessitates nutritional assessment. To meet recommended
needs of the patient, supplementation may be necessary.
Additional implications arise from the treatments associated with
cancer eradication--namely, surgery and radiation. 10 Surgery generally
alters the patients ability to eat during recovery. If part of the
digestive tract is removed, serious nutritional inadequacies may result
in adverse effects, such as a 5-10% weight loss. Radiation therapy
presents the additional complications of nausea and vomiting.
Fortunately, new anti-emetic and anti-nausea drugs may reduce the
severity of these adverse effects.
Years following radiation therapy, there also exists the possibility
of esophageal narrowing.1 Patients describe a feeling of food getting
caught in their chests. In most cases, a gastroenterologist can address
and resolve this issue. External radiation therapy also carries the
potential to cause dry and irritated skin in the later weeks of
treatment. If aimed at the chest, radiation therapy may lead to sore
throat, coughing, or shortness of breath. Dysphagia or painful
swallowing is common after several weeks of treatment. The patients
healthcare team must work together to suggest ways to manage these
issues during treatment, although treatment cessation generally
results in symptom digression.
D. Specific MNT used to treat the disease include any
evidence-based practice guidelines
The best resources that nutrition professionals can use for
treatment guidelines include the Evidence Analysis Library of the
Academy of Nutrition and Dietetics.10 Here, a summary of evidence for
nutrition treatment for the most relevant issues for practice in an
online, user-friendly library. The National Cancer Institute website is
another resource that provides an overview of nutrition in cancer care.
In all cases of nutritional cancer management, the
documentation of the patients weight history is key. Screening tools
such as the Subjective Global Assessment may identify risk without
clear manifestation of symptoms. The healthcare provider should
monitor food intake or other issues that may affect eating, such as a
decrease in appetite, taste, or ability to smell.

As a symptom of BE and EAC, GERD must be managed as part of

a medical nutrition therapy regimen. The US Department of Health
and Human services National Digestive Disease Information
Clearinghouse recommends lifestyle changes to help decrease the
occurrence of GERD.11 Individuals who experience GERD should avoid
large, high fat meals; eating before bed, smoking, alcohol, caffeine,
vigorous activity right after eating, acidic and spicy foods,
secretogogues, and triggers. Secretogogues increase gastric secretion
of HCl and include foods like coffee, alcohol, and some peppers,
amongst others. Triggers differ from individual and may include mint,
allium vegetables, tomato sauce, and chocolate. If an individual is
overweight, it is recommended that the individual bring weight within
recommended guidelines. Furthermore, GERD patients are often
treated with acid suppression drugs, such as antacids, which are
known to affect long term absorption of B12 and Fe. Thus, if the
patients are on acid suppression drugs for an extended amount of
time, B12 and Fe should be monitored and addressed should any
deficiency arise.
Dysphagia is a common complaint of individuals who are
diagnosed with esophageal cancer. Individuals, especially individuals
with inoperable esophageal cancer, must be put on a dysphagia diet
for the management of this symptom. Depending on the level of
severity of dysphagia as determined by a speech pathologist, the food
modifications differ. According to the dietary guidelines for the
national dysphagia diet, level one foods consist of thick, homogenous
pureed foods that require little to no chewing.12 Level 2 consists of
mechanically altered foods that are semi-solid. Level 3 consists of
several different texture foods that are easy-to-cut. Level 4 is
considered a normal diet and may include hard, sticky, and dry foods.
Level 1 is needed in cases of severe dysphagia whereas level 3 is
considered for less severe cases. Refer to table 1 outlining foods
served according to NDD status. The National Dysphagia Diet also
categorizes liquids into different levels - spoon thick, honey-like,
nectar-like, and thin. Thicker liquids are required for lower levels of
dysphagia.

National
Dysphagia
Diet12
Lev Type
el

Consistency

ND

Foods should be pureed to a

Dysphagia

Foods
1. Bread pre-gelled or

D 1 Pureed

smooth, cohesive,
homogeneous mixture.
Foods require little to no
chewing ability.

2.

3.
4.
5.

pureed into a thick

consistency
Fruits and veggies
completely pureed
with pulp and seeds
extracted
Mashed potatoes
with sauce or butter
Soups that are
pureed and smooth
No eggs, souffles, or
lumpy foods.

ND Dysphagia
Foods should be similar to
D 2 Mechanically- NDD 1 but can be semi-solid
altered
and moist. Foods require
some chewing ability.

1. Bread pregelled or
pureed into a thick
consistency
2. Fruits that are soft,
canned, or cooked.
Avoid canned
pineapple, seeds,
and not easily cut
fruit.
3. Vegetables cut into
small pieces. They
should be well
cooked and easily
mashed.
4. Meat that is most,
ground, and in
smaller pieces than
inch thick

ND Dysphagia
D 3 Advanced

Foods should be soft, solid,

and similar to normal
textures of foods. Foods
should not be hard, sticky, or
dry.

1. Breads and cereals

that are moist.
2. Fruits that are soft
and do not contain
seeds.
3. Meat that is moist,
tender, and cut into
small pieces
4. Avoid any foods that
are crunchy, sticky,
or dry.

ND Regular
D4

Foods are solid and do not

require texture changes.

1. Nuts and seeds

2. Potato skins and

chips
3. Corn
4. Raw vegetables
5. All foods
The primary concern of Dieticians with cancer patients is the loss
of lean body mass associated with dysphagia, carcinomas, and cancer
treatment.10 MNT is necessary to address protein and energy needs, as
well as to ensure adequate intake of iron, copper, magnesium, and B
vitamins. Body weight must also be carefully monitored, and the
survivor must be made aware of necessary weight loss or gain goals at
this stage. The Dietician is also responsible for communicating caloric
requirements and physical activity recommendations with the patient.
The potential for future development of chronic diseases like CVD,
diabetes, or osteoporosis must also be discussed with the patient,
along with corresponding guidelines for saturated and trans-fat, dietary
cholesterol, sodium, calcium, and vitamin D intakes. Such counseling
services many not be covered by medical insurance companies.
Financial coverage for MNT requires substantial proof of efficacy,
making printed materials and additional resources for the patient
particularly useful.
According to the Academy of Nutrition and Dietetics, Enteral
nutrition (EN) may be used to increase nutrient intake--primarily
protein and calorie intake--in esophageal cancer patients undergoing
radiation therapy.13 Evidence supports EN as a means to maintain
weight; however, EN has not been shown to improve survival rate or
tolerance to radiation therapy. Parenteral nutrition (PN), conversely,
should not be used as the higher cost, increased risk, and lack of
benefit associated with PN remain unjustifiable.
To improve EAC outcomes, the Dietitian should provide medical
nutrition therapy (MNT) that includes a pre-treatment evaluation and
weekly visits over a six-week span during chemoradiation treatment.
MNT provided by the Dietitian may reduce negative outcomes,
including: weight loss, unplanned hospitalizations, LOS, as well as
improve tolerance to treatment and the likelihood of receiving
prescribed radiation dose.
Part of the Dietitian's role is also to oversee the patients
transition from post-surgery NPO to a regular diet, as part of a surgical
team. In the immediate postoperative period until around day 5, an
esophagectomy patient will need to pass multiple tests to ensure that
no gastrointestinal leaks have developed.14 During this period, enteral
feeding should be prescribed and monitored by a dietician. If no leak
develops, oral intake of liquids may be initiated while jejunostomal
feeding continues to provide primary nutrition. If liquids are tolerated,

the dietician may oversee the patients transition to a soft diet. During
the period preceding hospital discharge, the dietician should monitor
the transition from a continuous tube feeding infusion to a cyclic
infusion over 12-14 hours to allow for oral intake during the day. In an
outpatient setting, regular visits, laboratory tests and chest X-rays
should be used to check for the development of complications.
Typical disease progression and treatment/cure (drugs,
surgery, etc.)The development of EAC is multi-step process, beginning with
the mucosal injury of the distal esophageal squamous epithelium and
progressing through intestinal metaplasia and dysplasia to invasive
adenocarcinoma.9 Mucosal injury often results from the introduction of
proinflammatory components into the esophageal lumen. Chronic
inflammation associated with GERD and Barretts esophagus results
from bile salt and acid exposure leading to chronic inflammation and
mucosal damage.15 The increase in pro-inflammatory mediators like
cytokines, chemokines, prostaglandins, and reactive oxygen/nitrogen
species may also promote mutagenesis and support tumor initiation
and progression, possibly acting as immunosuppressants in the
affected cells. Chemical exposure, as with tobacco consumption, may
also cause esophageal injury.
Treatment
Esophageal cancers at this stage must be treated surgically with
esophageal resection, lymphadenectomy and reconstruction with the
stomach followed by various combinations of radiation therapy,
chemotherapy, and immunotherapy. Two main procedures to remove
esophageal cancer are transhiatal esophagectomies and right or left
thoracotomies. Transhiatal esophagectomies ectomies have lower
morbidity rates than thoracotomies, however both procedures have a
19-57% failure rate of removing the cancer from the operated region. 16
Often times thoracotomies are combined with intrathoracic
anastomosis, a surgical procedure that connects the stomach to the
esophagus. The combination of a thoracotomy with intrathoracic
anastomosis is know as transthoracic esophagectomy.17 Transthoracic
esophagectomies allow for an accurate visual and removal of the
cancerous area. The procedure also shifts the liver and duodenum,
requiring an abdominal incision, in order for the stomach to be moved
into the neck. The duodenum is also shifted in order to perform a
pyloric drainage procedure which reduces risk of fluid retention,
dumping syndrome, and aspiration. A complication of transthoracic
esophagectomies is the risk of infection from possible anastomotic
leaks. Transhiatal esophagectomies are similar to transthoracic
thoracotomies by the number of incisions. Transhiatal esophagectomy

only have an abdominal incision whereas transthoracic

esophagectomies have a thoracic and abdominal incision.
Both transhiatal esophagectomies and transthoracic
esophagectomies are accompanied with surgical jejunostomies, in
order to give the patient enough time to rest and heal their upper GI
tract. Jejunostomies create a opening from the jejunum to the outside
of the skin. A catheter is placed in the hole to allow for enteral
feeding.
Patients diagnosed with EAC also typically undergo external
beam radiation therapy. External beam radiation therapy projects
radiation at small permanent tattoos on the outside of the skin that
represent the targeted area for therapy.1 This therapy lasts about 20
minutes and is repeated 5 times a week for 2-10 weeks depending on
the severity and location of the carcinoma. Inoperable cancer is
typically treated with both external beam radiation and chemotherapy.
For patients with localized EAC, surgical resection has been
shown to greatly increase survival rates. Guidelines from the National
Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in
Oncology and Gastrointestinal Cancer Evidence-based Series and
Practice Guidelines have recommended preoperative
chemoradiotherapy for resectable EAC as a preferred approach. 19 20
While surgery alone without preoperative therapies is thought of as
permissible for patients with comorbidities unsuitable for trimodality
therapy or patients with treatment preferences. Patients with
resectable node-positive EAC that undergo surgery alone may
experience a poor prognosis, having a five-year survival rate of less
than 15%.8 Single-modality surgery often results in local EAC
recurrences and lymph node or distant metastases, making adjuvant
treatments more appealing for both practitioners and patients.
Radiotherapy is a component of combined therapy for EAC. Generally
accepted as a means to reduce local recurrence of adenocarcinoma,
radiotherapy may be a more effective for non-metastasized
esophageal cancers as opposed to metastases-reducing
chemotherapies. In one study, patients with node-positive metastases
showed an improved five-year survival rate when receiving adjuvant
radiotherapy; however, convincing evidence exists that indicates that
adjuvant radiotherapy following a large esophagectomy is less likely to
improve disease-free and overall survival rates.
Nutrition Care Plan
Nutrition Assessment
Age: 56
Gender: Male
Ethnicity: Caucasian

Presenting Diagnosis: Stage IIB (t1, N1, M0) adenocarcinoma of

esophagus (node-positive)
Medical History: POD #4 s/p transhiatal esophagectomy
Relevant Social History: Married to wife (52) with 3 sons 18, 19, and
22. 18 year old lives at home while other two are at college. Works 12
hour days, 5-6 days per week as a contractor. Has some college
experience and considers himself catholic. Smokes 2 packs of
cigarettes a day and regularly consumes alcohol. Lost 30 lbs over last
several months and says he has not been able to eat due to heartburn
and pain. Has trouble swallowing foods especially with texture.
Experiences cough at night. Odynophagia for past 5-6 months and
dysphagia for past 3-4 months.
Anthropometrics:
Height: 63; 63 = 75 inches. 75 inches x 2.54 cm = 190.5 cm.
109.5 cm/100 = 1.9 M
Weight: 198 lbs; 198 lbs/ 2.2 kg = 90 kg
UBW: 230 lbs (overweight) ; 230 lbs/ 2.2 kg = 104.5 kg
IBW: 184 lbs + or - 10% (normal); 106 lbs + 6 lbs (13 inches) =
184 lbs 184 lbs/2.2 kg = 83.6 kg; 184 lbs - 18.4 lbs = 165.6 lbs;
184 lbs + 18.4 lbs = 202.4 lbs; ibw range = 165.6-202.4 lbs
BMI: 24.9 (healthy weight); 90 kg/ 1.9 m2 = 24.9
% Usual Weight: 86% (mild malnutrition); 198 lbs/230 lbs = .86
x 100% = 86%
% Std. Weight: 107% (normal); 198 lbs/184 lbs = 1.07 x 100 =
107%
Laboratory Values:

Complete Blood Count

Type

Admitted 9/5
value

Post-op 9/11
value

Indications respectively

WBC

5.2 x 103/mm3

6.9 x 103/mm3

Normal

RBC

4.2 x 106/mm3

4.3 x 106/mm3

Low - indicates low Iron

levels

HGB

13.5 g/dL

13.9 g/dL

Low - indicates low iron

levels

HCT

38 %

38 %

Low - indicates low iron

levels

MCV

90 microm3

86 microm3

Normal

RETIC

.9%

1%

Normal

MCH

32.4 pg

32.3 pg

Normal

MCHC

35.5 g/dL

36.5 g/dL

Normal

RDW

11.9%

23.1%

Normal

Plt Ct

250 x 103/mm3

232 x 103/mm3 Normal

ESR

17 mm/hr

15 mm/hr

High; normal

%
75%
GRAINS

65%

Normal

%LYM

25%

35%

Normal

SEGS

55%

65%

Normal

BANDS

4%

3%

Normal

LYMPHS 28%

32%

Normal

MONOS 4%

5%

Normal

EOS

0.6%

Normal

FERRITI 220 mg/mL

N

208 mg/mL

Normal

PT

12.8 sec

Normal

0.5%

12 sec

Negative Acute Phase Proteins

Lab

Admitted 9/5
value

Post-op 9/11
value

Indications respectively

Albumin

3.1 g/dL

3.0 g/dL

Low - indicates
inflammation

Prealbumi 15 mg/dL
n

12 mg/dL

Low - indicates
inflammation

Transferri 285 mg/dL

n

175 mg/dL

Normal; Low - indicated

inflammation

Total
Protein

5.7 g/dL

Low - indicates sarcopenia

5.7 g/dL

Current Treatment: External Beam Radiation Therapy; tube feeding

via jejunostomy
Kcal, protein requirements:
Rule of Thumb: 2,700 Kcals; 90 kg (30 kcals) = 2700 Kcals
Protein: 135 g; 90 kg x (1.5 pro post op) = 135 grams
Fluid: 2,700 mL
Diet Order appropriateness: Doctor prescribed a Jejunal feeding
tube to be injected with Isosource
HN of 1.5 kcal at 75 mL/hr x 24 hrs. 24 hour enteral feeding
may be better substituted with 18 hour enteral feeding. The
isosource prescription accurately estimates energy needs in
Isosource HN mL per hour, but is inaccurate in the starting rate.
The prescription was also high in protein and low in water.
Energy: 2700 kcals / 1.5 kcals/mL = 1,800 mL/day is required to
meet energy needs. Dividing the mL of Isosource HN by the
prescribed 24 hours results the goal rate.
Goal Rate: 1,800 mL/24 hrs = 75 mL/hr goal rate. Patient was
started at 75 mL/hr however, the prescription should have
started at half the goal rate, which is equivalent to approximately
37.5 mL/hr. The correct way to introduce the patient to enteral
feeding is at 37.5 mL/hr. Then the patient should be monitored
for tolerance of feeding. If the feeding is tolerated, 10 mL
increments should be added to the initial rate every hour until
goal rate is reached.
Protein: Formula is 18% protein per 1000 mL, thus there are 180
grams of protein per 1000 mL. 180/1000 mL = grams of protein
a day/1,800 =324 grams of protein a day. Patient is receiving
over recommended for post-operative status. However, higher
protein needs are required for the low total serum protein from
muscle breakdown before surgery.
Fluid: Fluid is 82% of 1000 mL and thus gives 820 mL of water
per 1000 mL. 820 mL/1000 = water from Isosource HN a
day/1,800 x = 1,476 mL of water from Isosource HN a day. The
patient should be should be flushed with 1,224 mL of water
spread throughout the day.
Medications with action and nutrient interactions noted: hx of
Tums and Alka-Seltzer.
Other treatments: N/A
Nutrition Diagnosis
Suboptimal nutrient intake from all sources less than projected needs
related to transhiatal esophagectomy and radiation therapy for the
treatment of esophageal adenocarcinoma as evidenced by low albumin

of 3.0 g/dl, low prealbumin of 12 mg/dL, low transferrin of 175 mg/dL,

low RBC of 4.3 mcg/mm3, hemoglobin of 13.9 g/L, hematocrit of 38%,
and low total serum protein of 5.7 g/dL .
Nutrition Intervention
Plan:
1. Nutrition Intervention using the Domain and sub-category terms:
a. ND3: Supplementation- supplement iron to address irondeficiency symptoms.
b. C2: Explain to the patient the strategy of self-monitoring in
order to allow for early detection of nutrition-related
complications
c. ND2. Prescription of the composition 18% protein, rate 75
mL/hr, and schedule 18 hours of enteral nutrition.
2. Nutrition prescription for this patient and identify intervention
strategies:
a. EER= 2,700/day
b. Protein = 135 g/day
c. Fluid = 2,700 mL/day
d. Goal rate = 75 mL/hr for 18 hours
e. Goals:
a. Patients Fe levels will return to a normal range with
Fe supplementation via absorbable Fe in enteral
formula.
b. Patient will understand how to address the nutritional
implications of cancer and beam radiation therapy
c. Patient will transition from enteral to oral feeding
while maintaining adequate nutrient intake of 2,700
kcal/day and 135g protein/day in order to decrease
sarcopenia and maintain a healthy body weight with
radiation therapy.

Implementation:
1) Action:
a) Provide Fe supplement in enteral formula
b) Provide an appropriate timeline in which to introduce liquids (5-6
days post-operative) , soft foods (as tolerated, before discharge
from the hospital), and then regular foods into the patients diet.
c) Educate client on foods high in lacking nutrients

d) Educate client on how to improve tolerance to radiation

treatment, including how to maintain adequate consumption and
weight by increasing energy dense foods in diet.
e) Provide patient with educational materials and counseling about
lifestyle modifications that reduce the risk of EAC recurrence,
such as smoking cessation and alcohol consumption in
moderation.
Monitoring:
1) FH1- Regularly monitor enteral nutrition intake via formula or
solution, B12 intake, iron intake, over the counter medication intake,
and food intake (quantity).
2) BD1- Monitor hemoglobin and hematocrit values to assess
nutritional anemia profile and the possible need for a new
intervention strategy.
3) BD1.11- Monitor albumin, prealbumin, and transferrin levels to
assess the patients protein status throughout treatment and to
determine the need for additional intervention.
4) AD1- Monitor patient weight changes in order to determine the
effectiveness of nutrition intervention.
5) PD1- Monitor tolerance of enteral nutrition by assessing abdominal
distention, nausea, and vomiting.
Evaluation:

Patients serum hemoglobin, hematocrit, and RBC levels will be

compared to the average values of 14-17 g/dL, 40-54 %, and 4.56.2 x106/mm3 respectively.
Patients protein profile of transferrin, prealbumin, and albumin
will be compared to normal values of 215-365 mg/dL, 16-35
mg/dL, and 3.5-5 g/dL respectively.
Patients weight will be compared to his usual body weight,
before illness occurred.
Patients abdominal distention, nausea, and vomiting will be
compared to abdominal distention, nausea, and vomiting before
enteral feeding
Patients use of acid suppressants will be compared to acid
suppressant intake before surgery

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National Cancer Institute. What you need to know about cancer of the esophagus.
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