Clinical Case Study Whitney Houser KSC Dietetic Intern

Clinical Case Study Whitney Houser KSC Dietetic Intern February 6 th 2013

Role of the RD The role of the RD is to assess nutrition status as hospital stay continues, monitor bowel function, PO, appetite, assess needs (nutrition and educational), provide education, provide referral as needed (suggest consult, outpt. f/u) encourage appropriate intake. Diet techs are responsible for all moderate to low risk patients.

Concord Hospital Formerly known as Margaret Pillsbury General hospital opened its doors in 1891. It grew into Concord Hospital by 1946. 114 acres, 2, 650 staff members, 352 medical hospital staff with 235 staffed beds. Serving nearly 18, 000 patients per year Mission Statement: “Concord Hospital is a charitable organization which exists to meet the health needs of individuals within the communities it serves. ” Baby friendly hospital Nearly 40 specialties and subspecialties, particularly known for: cardiovascular care, urology, cancer care, orthopedic surgery and women’s health.

Assessment: Mr. B 86 yo male, admitted 01/21/13. Admission Dx: Muscle invasive bladder cancer Procedure: Open radical cystectomy with ileal conduit, urinary diversion. Social Hx: Retried geologist, WWII vet: worked all over the world from oil fields in Texas, mines in Colorado, all the way to Africa. Pipe smoker, light drinker. Lives with wife of 20 yr who has metastatic breast cancer. Enjoys spending time with grandchildren.

Anthropometrics Height: 5’ 5” Weight: 61 kg (134 lbs) UBW: 51 kg (1 yr ago: 7% loss) BMI: 22. 4

Medical History • Prostate Cancer, s/p combination external beam and interstitial seed implant • Incontinence • Macrocytic anemia • Hernia repair • Memory loss • Mild dementia • Hyperlipidemia • COPD w/o exacerbations • Lung nodules

Diagnosis Microscopic Dx: Two bladder biopsies revealed soft tissue density within left bladder base, extending into trigone. Right posterior smooth muscle, left walls and surrounding lymph nodes biopsied and benign. Pre-op workup revealed he was safe for surgery, despite age. Question of waiting vs surgery vs palliative. Pt opted for surgery to “be there for his wife. ” Per surgeon: Opted for open surgery vs robotic because of previous radiation therapy to prostate and scar tissue build up.

Meds (PTA, In Hospital) Prior to Admission Vitamins/Minerals: B 12 (for macrocytic anemia) B 6 Glucosamine (for osteoarthritis, osteoporosis) Vit. C Vit. A Lutein (beneficial in preventing the progression of age related macular degeneration) Calcium/Vit. D (for osteoarthritis, osteoporosis) Other antioxidants (for macular degeneration—recommended by his eye doctor) In Hospital Heparin (for DVT prophylaxis) Zofran and Reglan (for nausea) Epidural for pain mgt (4 cc/hr, demand dose 2 cc) B 12 Vit. D/Ca

Labs, Needs Significant labs upon admit (01/21/13) BUN 22 Ca 7. 8 HH 10. 9/33. 2 MCV 99 Estimated Needs 1, 600 k. Cal (Mifflin x 1. 3) 73 -86 g Pro (1. 2 -1. 4 g/kg) 1, 528 ml fluid (25 ml/kg)

Pathophysiology Cancer is a disease characterized by uncontrolled proliferation of cells.

Pathophysiology 3 Types of Bladder Cancer • Urothelial carcinoma • Squamous cell carcinoma • Adenocarcinoma 1 in 42 men and women will be diagnosed with bladder cancer within their lifetime -National Cancer Institute

Etiology/Risk Factors Age Race Gender Medical history (Family, Personal) Lifestyle factors 2013) (Cleveland Clinic,

Etiology/Risk Factors 50% of bladder cancer incidences is related to tobacco smoking 20 -25% from long-term workplace exposure to toxins Pathophysiology Carcinogens are filtered from the bloodstream through the kidneys and eliminated from the body via urine. Inner cellular lining of bladder is exposed to these carcinogens while they sit in the urinary storage waiting for elimination. Cellular exposure over time can lead to genetic mutation and subsequent carcinogenesis.

Signs, Symptoms, Diagnosis Hematuria Pain during urination Frequent night time urination Urge without ability to pass urine Unexplained appetite loss Unintentional weight loss Diagnosed via cystoscope , followed by bladder biopsy.

Disease Progression Most bladder cancers are noninvasive, easily treatable. Cancer typically begins in urothelium lamina propria (muscle) perivesicle fat When it becomes muscle invasive, it is likely to metastasize to surrounding organs. Most commonly metastasizes to lungs, liver. High recurrence rate of 50 -80%: Related to high grade nature of tumors. (National Cancer Institute)

Medical Treatment Surgery: non-invasive, invasive Chemotherapy: Adjuvant therapy Palliative care & Pain management (The Nature Clinical Practice Urology)

Urinary Diversion: Ileal Conduit 1. Piece of terminal ileum is surgically removed. 2. Piece is reattached to the ureters and a stoma is created. 3. Stents are attached to ureters which carry urine through the stoma into a urostomy collection pouch.

Ileal Conduit: Research The Journal of Urology, 1992: “Since intestine was not meant to serve as either a conduit or storage vehicle for urine, the use to which it is put in urology, numerous complications may occur in the short and long term…the duration that the intestinal segment has been in the urinary tract has also been suggested as a determinant of solute absorption. It has been suggested that the activity of transport processes diminishes with time. ” Advances in Urology, 2011: “ The duration of contact between urine and bowel, the segment and length of bowel used are factors that determine the nature and grade of metabolic effects…In the bowel, sodium is secreted in exchange of hydrogen and bicarbonate is secreted in exchange of chloride. In parts of bowel that are exposed to urine, ammonia, ammonium, hydrogen, and chloride are reabsorbed as well. As a consequence, the presence of an ileal and/or colonic urinary diversion always implies a chronic acid load. ”

Implications Diarrhea Malabsorption Hyperchloremic metabolic acidosis is baseline B 12 deficiency Bone loss Issues surrounding pre-existing renal insufficiency Why the ileal segment? According to Nutritional Issues in Gastroenterology from the University of Virginia Medical School: “It has good mobility with relatively long and anatomically constant vessels, the caecum rarely has diverticula, easy harvesting and reanastomosis. ”

Medical Nutrition Therapy Maintain adequate energy and protein intake Avoid dehydration B 12 supplementation Increased dietary fiber intake; cholestyramine meds. Oral sodium bicarbonate Calcium/Vit D supplementation

Mr. B Nutrition Status: PTA Intake variable Appetite poor Wife ‘forced’ him to drink Ensure Per Pt: Supplements killed appetite Diarrhea: Wife tried to increase fiber, unsuccessful Unintentional wt loss

Hospital Course Jan 21: Admission • NG tube for suction • 5% dextrose in lactate ringers (100 ml/hr) • 2 -JP tubes for drainage • Braden 19 • Morphine PCA Jan 24: #2 Nutr. Meeting • NPO • Not chewing gum as advised • N/V • n/d, tender • Stoma teachings today, RN • Sodium 135 Jan 22: Initial Nutr. Meeting • NPO • Pt confused post-op • Wt, diet hx from wife • Decreased urine output • IV bolus x 3 • Decreased strength, mobility • Hungry, may chew gum • Conduit lessons today, RN Jan 25: #3 Nutr. Meeting • NPO • Nutr support if no diet adv. • IVF 125 ml/hr • Gas pain relieved • BG 129 Jan 23 • NPO • Abd t/d • Low urine output • High JP output • Gas pain • Epi removed, leaking • BG 130 Jan 26 • Constipation • NPO x 6 • Suppository given w/ effect • Urine neg. for creatinine

Hospital Course Jan 27: Jan 28: • Diet Adv. To Clears • BM • No gas • 50% breakfast noted • High JP output • Chloride 108 • BUN 6 • Ca 7. 2 • Diet Adv. To Fulls • BM—very small • Gas • 100% breakfast/dinner Jan 29: #4 Nutr Meeting • Diet Adv. To Reg. • Supplements started • 100% B/L • Nt/d • Cal Count started • 64% kcal needs met • 67% pro needs met Jan 31: Final Nutr. Meeting • <15 min High calorie/pro education with pt and wife • Pt discharged Jan 30: #5 Nutr. Meeting • 57% kcal needs met • 54% pro needs met • s/nd • IVF d/c

Intervention Goals: Await diet adv. , transition to PO, increase intake, meet needs, increase knowledge. Encouraged gum chewing to stimulate bowel 2009) (Journal of Gastrointestinal Surgery, Emphasized importance of adequate fluid intake upon diet adv. Recommended whole milk at meals Encouraged intake through supplementation Ordered Calorie Count to gauge intake, need for nutr. Support Provided high cal/pro nutrition education to pt and family

Monitor/Evaluate PO Appetite Bowel function Reassess needs as appropriate

Outcomes, Discharge Planning Educational needs met: conduit lessons, high cal/pro education, follow up materials and RD number given. Nutritional needs met: Progressed to a regular diet, meeting over 50% of needs after NPO x 6. Discharged home w/o VNA at pt’s wife request

References Stenzl A, Cowan C N, De Santis M, et al. The Updated EAU Guidelines on Muscle-Invasive and Metastatic Bladder Cancer. European Urology. 2009; (55): 815 -825. http: //eu-acme. org/europeanurology/upload_articles/Stenzl. pdf. Accessed February 1, 2013. Said N, Sanchez-Carbayo M, Smith S C. , Theodorescu D. Rho. GDI 2 Suppresses Lung Metastasis in Mice by Reducing Tumor Versican Expression and Macrophage Infiltration. J Clin Invest. 2012; 122(4): 1503 -1518. http: //www. sciencedaily. com/releases/2012/03/120312140246. htm. Accessed February 1, 2013. Gakis G, Stenzl A. Ileal Neobladder and Its Variants. European Urology Supplements. 2010; (9): 745 -753. http: //eu-acme. org/europeanurology/upload_articles/Georgios%20 Gakis, %20 Arnulf%20 Stenzl. pdf. Accessed February 3, 2013 Up-to-date website. http: //www. uptodate. com/contents/bladder-cancer-treatment-non-muscle-invasive-superficialcancer-beyond-the-basics. Bladder cancer treatment; non-muscle invasive (superficial) cancer (Beyond the Basics). O’Donnell, Michael A. MD, FACS. Accessed February 2, 2013. Taylor, J. Kuchel, G. Vega, C. Bladder Cancer in the Elderly: Clinical Outcomes, Basic Mechanisms, and Future Research Direction. Nat Clin Pract Urol. 2009; 6(3). http: //www. medscape. org/viewarticle/589047. Accessed February 3, 2013. Memorial Sloan-Kettering Cancer Center website. http: //www. mskcc. org/cancer-care/adult/bladder/diagnosistreatment-msk. Accessed February 2, 2013

References American Society of Clinical Oncology, website. http: //www. cancer. net/cancer-types/bladder-cancer/symptoms-and -signs. Accessed February 3, 2013. Van der Aa F, Joniau S, Van Den Braden M, Van Poppel H. Metabolic Changes after Urinary Diversion. Advances in Urology. 2011. Article ID 764325. http: //www. hindawi. com/journals/au/2011/764325/ Accessed February 3 2013. Rodriquez K, Albright M. The Use of Chewing Gum to Prevent Post-Operational Ileus in the Open Abdominal Surgical Adult Patient on a Post-Operative Unit: A Literature Review. Gastro Surg Unit, Oschner Med Cnt. http: //academics. ochsner. org/uploaded. Files/Research/Nursing/rodriguezposter. EBP. PDF Accessed: February 2 2013. Steinberg G, Katz M. Bladder Cancer, website. http: //www. emedicinehealth. com/bladder_cancer/article_em. htm. Accessed February 1, 2013. Stein J, Lieskovsky G, Cote R, Groshen S, et al. Radical Cystectomy in the Treatment of Invasive Bladder Cancer: Long-Term Results in 1, 054 Patients. J Clin Oncology. 2001. (19): 666 -675. http: //jco. ascopubs. org/content/19/3/666. short Accessed February 3 2013. Davis-Dao C, Henderson K, Sullivan-Halley J, Ma H. et al. Lower Risk in Parous Women Suggests That Hormonal Factors Are Important in Bladder Cancer Etiology. Cancer Epidemiological Biomarkers Prev. 2001; (20): 1156. http: //cebp. aacrjournals. org/content/20/6/1156. short. Accessed February 2 2013.

References Kaufman D, Shipley W, Feldman A. Bladder Cancer. The Lancet. 2009; 374 (9685): 239 -249. http: //www. thelancet. com/journals/lancet/article/PIIS 0140 -6736(09)60491 -8/fulltext. Accessed February 3, 2013. Academy of Nutrition and Dietetics. International Dietetics & Nutrition Terminology Reference Manual: Standardized Language for the Nutrition Care Process. 4 th ed. Chicago, IL: Academy of Nutrition and Dietetics; 2013: 415. Escott-Stump, Sylvia. Nutrition and Diagnosis-Related Care. 7 th ed. Baltimore, MD: Lippincott Williams & Wilkins, a Wolters Kluwer business. 772 -774. The patient content of this case study was gathered from Horizon Clinical EMR, H/P, therapy notes, preop consult notes and directly from the patient care team (RN, MD, social work, RD).