Cancer Note for Denise November 25th, 2014 8:00am

Heading (1
point)

S
(6 points
total)

(2 points)

3/08/2014:
I have continued to feel run down since I had the flu.
I still have a fever sometimes, and the cough wont go away.
Describes having to change her nightgown and bedclothes due to
excessive sweating.
Radiotherapy is planned to start 3 weeks after the third cycle of
CHOP.

3/30/2014:
Patients mother states:That Ms. Mitchells mouth hurts so badly
that she can hardly talk.
She has had only pureed foods, vegetable juices, and a little water
over the last 3 days.
Patients aunt and uncle introduced her to a special anticancer
diet.
She was told to only eat natural foods without any meat or dairy
products.
Patient says she doesnt know what to believe about this diet
stuff.
Patient is day 20 post initiation of chemotherapy regimen of
cyclophosphaside, doxorubicin, and prednisone. She is scheduled
to begin radiation therapy after third course of chemo.

O
(4 points)

3/08/2014:
Female
Age: 21
Height: 66 Weight: 120 #
UBW: 130#
IBW: 130.5#
BP: 95/70
Pulse: 85 bpm
Body Temperature: 100.5 Degree Fahrenheit
REE: 1336 kcal
TEE: 1737
BMI: 17.4
Irregular Biochemical Lab Values
Albumin: 3.0 L g/dL
Total Protein: 5.4 L g/dL
Creatinine: 0.4 L mg/dL
Cholesterol: 120 L mg/dL
Patient history: Cold in past two weeks, tonsillectomy at age 5
Treatment Plan: Chemotherapy regimen of cyclophosphamide,
doxorubicin, vincristine, and prednisone (CHOP)
Medications: Dimetapp

Previous Hospitalizations/surgeries:
Biopsy last admission for diagnosis of stage !! diffuse large B-cell
Lymphoma
Medication: 250 mg Tylox every 6 hours

3/30/2014:
Weight: 108 # Weight change: 12#
REE: 1400 Kcal
TEE: 1800 kcal
BMI: 19.4
IBW: 130.5#
BP: 95/70
Body Temperature: 102.5 degrees fahrenheit
Irregular Biochemical Lab Values:
HGB: 9 L g/dL
MCV: 65 fL
MCH: 22 L pg
Family History: Cancer in paternal grandfather, heart attack
paternal grandfather, angina/chest pain and high blood pressure
paternal grandfather
Nutrition History: Appetite decreased. No nausea, vomiting,
constipation, or diarrhea.
Diagnosis: Immunosuppression, candidiasis fungal infection, and
dehydration, R/O pneumonia
Nutrition Plan: Nutrition consult and begin with nystatin swish and
swallow
24-hour recall:
kcal: 80
protein: 3g
CHO: 18g

Dx:
____points
Dx:
____points
Dx:
____points

(9 points)
(Each PES
statement is worth
3 points, unless
you had fewer than
three.
One=9 points;
Two=4.5 points
each.)

I (M/E)

I:
____points

(6 points)
(3 points for
Intervention; 3

Inadequate protein-energy intake (NI-5.3) related to candidiasis as

evidenced by current low calorie intake, unintended weight loss,
physical appearance, patient comments, decreased serum
albumin levels, family restricting meat and dairy products.

Limited adherence to nutrition-related recommendations (NB- 1.6)

related to family pressure to follow an anti-cancer diet as
evidenced by family members restricting certain foods from her
diet, patient comments, desire for a cure for her cancer through
the use of the anti-cancer diet, not adhering to previous RD
recommendation of high calorie high protein diet.

1. Nutrition Education (E-1.1)

Related to disease for the patient and her family.
Provide education related to modified food consistencies
and foods that arent as acidic
Provide education to patient and family concerning the
importance of protein and adequate calories in the diet

points for M/E.)

2.

3.

4.

5.

M/E:
____points

Signature
(1 point)

Recommend increased calorie intake

by 500 kcal for 1lb weight gain
Provide commercial beverage (ND- 3.1.1)
Ensure Plus (2x-3x daily or as tolerated) to provide 7001,050 kcal and 26-39g Protein
Provide texture modified diet (ND- 1.2)
Recommend softer texture foods to aid with candidiasis
Referral to physician (RC- 1.5)
Request additional information regarding physical activity,
average daily intake before treatment, chemotherapy
schedule and dosage, what all was discussed at previous
nutrition consult, TSF, midarm circumference, temporal
wasting (if any).

1. Monitor and Evaluate areas of knowledge/skills related to

food sources high in protein
2. Monitor knowledge of modified food consistencies and
non-acidic foods
3. Monitor total energy intake
4. Monitor and evaluate effectiveness of the Nystatin swish
treatment, ordered previously from the physician, in aiding
candidiasis
5. Monitor candidiasis condition
6. Monitor and evaluate intake of Ensure Plus
7. Monitor calorie intake and weight gain/loss
8. Monitor serum albumin levels
Amy Reinhard
Adria Bucheli
Sara Katula
Emily Glaser
Makenzie Shanks
Carlie Rider
Overall impression of the note. Writing style, neatness

Writing
Style
(2 points)