Heading (1
point)
Cancer Note for Denise November 25th, 2014 8:00am
A
S
3/08/2014:
(6 points
total)
(2 points)
“I have continued to feel run down since I had the flu.”
“ I still have a fever sometimes, and the cough won’t 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:
Patient’s mother states:That Ms. Mitchell’s 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.
Patient’s 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 doesn’t 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
3/08/2014:
(4 points)
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
D
A
Dx:
(9 points)
____points
Dx:
____points
Inadequate protein-energy intake (NI-5.3) related to candidiasis as
evidenced by current low calorie intake, unintended weight loss,
(Each PES statement physical appearance, patient comments, decreased serum
is worth 3 points,
albumin levels, family restricting meat and dairy products.
unless you had
fewer than three.
____points
One=9 points;
Two=4.5 points
each.)
I (M/E)
P
I:
(6 points)
1. Nutrition Education (E-1.1)
____points
(3 points for
Intervention; 3
points for M/E.)

Related to disease for the patient and her family.

Provide education related to modified food consistencies
and foods that aren’t as acidic

Provide education to patient and family concerning the
importance of protein and adequate calories in the diet
Dx:
Limited adherence to nutrition-related recommendations (NB1.6) 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.
2.
Recommend increased calorie intake

3.
Provide commercial beverage (ND- 3.1.1)

4.
Ensure Plus (2x-3x daily or as tolerated) to provide 7001,050 kcal and 26-39g Protein
Provide texture modified diet (ND- 1.2)

5.
Recommend softer texture foods to aid with candidiasis
Referral to physician (RC- 1.5)

M/E:
by 500 kcal for 1lb weight gain
Request additional information regarding physical activity,
average daily intake before treatment, chemotherapy
schedule and dosage, what all was discussed at previous
____points
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
Signature
(1 point)
Amy Reinhard
Adria Bucheli
Sara Katula
Emily Glaser
Makenzie Shanks
Carlie Rider
Writing
Style
(2 points)
Overall impression of the note. Writing style, neatness