Karly ChildressDenielle SaittaMolly ChaffinClaire HolladayLauren Mitchell

CASE STUDY #32ACUTE LYMPHOBLASTIC

LEUKEMIA TREATED WITH HEMATOPOIETIC STEM CELL

TRANSPLANTATION

Leukemia is a type of cancer that affects the blood and bone marrow

Common Types of Leukemia: Acute Myeloid Leukemia (AML) Acute Lymphoblastic Leukemia (ALL) Chronic Myeloid Leukemia (CML) Chronic Lymphocytic Leukemia

Patients with acute leukemia have a more aggressive disease than those with chronic leukemia

ACUTE LYMPHOBLASTIC LEUKEMIA

ALL, CON’T.

Bone marrow makes blood stem cells that become mature blood cells over time

A blood stem cell may become a myeloid stem cell or a lymphoid stem cell

Myeloid stem cell becomes one of three types of mature blood cells Red blood cells Platelets White blood cells

Lymphoid stem cell becomes a lymphoblast cell and then one of three types of lymphocytes B lymphocytes T lymphocytes Natural killer cells

SIGNS AND SYMPTOMS OF ALL

Hematopoietic stem cell transplant is a procedure that restores stem cells that have been destroyed by high doses of chemotherapy and/or radiation therapy

Three types of transplants: Autologous transplant Allogeneic transplant Syngeneic transplant

HEMATOPOIETIC STEM CELL TRANSPLANTATION

MEET SCOTT BEAR

Personal History 28 year old, white male Marital Status: Married with three children Tobacco use: ½ pack daily, states he “quit this morning” Alcohol use: 1 drink daily, beer or alcohol Mobility: Ambulatory

Hematology/Oncology History Chief Complaint: “I’m here to get some new cells.” Diagnosed with ALL in 2008 He was doing well until Spring 2012

Admitted with fever, fatigue, dyspnea, and red spots on his skinDiagnosis: Relapse of Pre-B cell ALL and started on HyperCVAD (5 cycles prior to admission)

CLIENT HISTORY (CH)

Musculoskeletal History osteomyelitis, back pain

Psychological History anxiety, depression

Family History Mother: Diabetes Father: Hypertension

Other History Obesity

Treatments/Therapy Surgical treatment

ALL admitted to the transplant unit for a 10/10 HLA matched unrelated donor transplant with myeloablative cyclophosphamide and total body irradiation

CLIENT HISTORY (CH)

■ Admission Orders (11/7) ALT/AST, Bilirubin: total and direct CMV, PT, IRN, PTT: on admit and every Monday/Thursday Calcium/Phosphate: on admit and every Monday/Thursday CVC, Edit, Platelet: on admit and every two days Chem 7, Magnesium: on admit and daily Prealbumin: on admit

Vital Signs Every 4 hours

Diet: Regular/Low bacterial

CLIENT HISTORY (CH)

Height: 5’9’’

Weight: 198 lbs

BMI: 29.4 kg/m2

Overweight

50lb unplanned weight loss during first round of chemotherapy (2008) 22% unplanned weight loss Regained 20 lbs to current 198lb

ANTHROPOMETRIC MEASUREMENTS (AD)

Upon Admission (11/7) Overall Appearance

Comfortable, not in acute distress, well-nourished Skin warm and dry, not perspiring

Chest/Abdomen Clear to auscultation Abdomen: soft, nontender, nondistended

Vital Signs Temp: 98.2 Pulse: 80 Resp rate: 16 BP: 126/78

NUTRITION-FOCUSED PHYSICAL FINDINGS (PD)

16 days post-op Overall Appearance

Macropapular rash on palms and trunk Grade 2 mucositis in mouth

Chest/Abdomen Clear to auscultation Firm, tense – hyperactive BSx4

Vital Signs (16 days post-op) Temp: 98.4 Pulse: 83 Resp rate: 20 BP: 130/82

NUTRITION-FOCUSED PHYSICAL FINDINGS (PD)

Lab Reference Range

Admission Post-op day 16

BUN (mg/dL) 8-18 13 23 H

BUN/Crea ratio 10.0-20.0 13 23 H

Albumin (g/dL) 3.5-5 3.5 2 L

Prealbumin (mg/dL)

16-35 24 <1 L

BIOCHEMICAL DATA, MEDICAL TESTS AND PROCEDURES (BD)

Hematology Lab

Reference Range

Admission Post-op day 16

WBC count (x103/mm3)

4.8-11.8 4.5 L 2.9 L

RBC count (x106/mm3)

4.5-6.2 (M) 2.82 L 2.33 L

Hemoglobin (Hgb, g/dL)

14-17 (M) 9.8 L 7.9 L

Hematrocrit (Hct, %)

40-54 (m) 29.1 L 23.7 L

Mean Cell Hgb (pg)

26-32 20.4 L 16.5 L

RBC distribution (%)

11.6-16.5 7.6 L 8.9 L

BIOCHEMICAL DATA, MEDICAL TESTS AND PROCEDURES (BD)

48-hour food recall shows regular and sufficient food intake

Likely meeting >100% of calorie and protein needs

FOOD AND NUTRITION-RELATED HISTORY (FH): FOOD AND

NUTRIENT INTAKE

FOOD AND NUTRITION-RELATED HISTORY (FH): FOOD AND

NUTRIENT INTAKECurrent Medications upon admission (11/7)

FOOD AND NUTRITION-RELATED HISTORY (FH): FOOD AND

NUTRIENT INTAKEMedication Plan as of 11/30

Medication Plan as of 11/30, con’t

FOOD AND NUTRITION-RELATED HISTORY (FH): FOOD AND

NUTRIENT INTAKE

Medication Plan as of 11/30, con’t

FOOD AND NUTRITION-RELATED HISTORY (FH): FOOD AND

NUTRIENT INTAKE

REE (using Mifflin St. Jeor equation): (10 x 90 kg) + (6.25 x 175cm) – (5 x 28 y) + 5 = 1,858.75

kcal/day

TEE 1.2 Activity Factor (hospitalized)= 2,230 kcal 1.0-1.3 injury factor due to surgery

2,230-2,900 kcal/day

COMPARATIVE STANDARDS (CS)

Macronutrient needs Normal protein requirements (0.8-1.0 g/kg body weight)

= 72-90 g/day Post-operative needs (1.0-1.5g/kg body weight)

= 90-135 g/day

Fluid needs: 1mL/kcal consumed 2.2-2.9 L/day = 9 (8 oz.) glasses per day

Fiber needs = 31 g/day

COMPARATIVE STANDARDS (CS)

Micronutrient Needs Calcium: 1,000 mg/day Vitamin D: 15 mcg/day Potassium: 4,700 mg/day Selenium: 55 mcg/day Vitamin B6: 1.3 mg/day

COMPARATIVE STANDARDS (CS)

PES #1: Altered GI function (NC-1.4) related to chemotherapy and

total body irradiation as evidenced by 3.5 L liquid stool past 24 hours.

PES #2: Altered nutrition related lab values (WBC, NC-2.2) related to

cancer treatment as evidenced by 2.9 White blood cell count.

NUTRITION DIAGNOSES

PES #1: Altered GI function (NC-1.4) related to chemotherapy and total body irradiation as evidenced by 3.5 L liquid stool past 24 hours.

Nutrition Rx: Meeting nutritional needs through bypassing the GI tract..

Nutrition Intervention: Initiate Parenteral Nutrition (2.2) Dextrose: 571 mL ; D70 ; 400g 1360 Kcals AA: 900 mL ; 15% AA; 135g 540Kkcals IVFE: 200 mL ; 20% IVFE ; 40g 400 Kcals

Total: 2,300 Kcals

NUTRITION INTERVENTION

PES #2: Altered nutrition related lab values (WBC, NC-2.2) related to cancer treatment as evidenced by 2.9 White blood cell count.

Nutrition Rx: Modify diet to a low microbial diet with high protein, adequate energy.

Nutrition Intervention: A low microbial diet includes avoiding raw/undercooked foods such as seafood, eggs, vegetables, undercooked meats, unpeeled fruits, or unpasteurized dairy products. This diet will reduce the chance of Mr. Bear becoming ill while his immune system is weak. Educate the patient on the importance of food safety and how this contributes to the low microbial diet.

NUTRITION INTERVENTION

Monitor anthropometrics by checking weight, BMI, and waist circumference to prevent weight loss

Evaluate the patients knowledge of the microbial diet and what he should and should not eat when his immune system is suppressed

Evaluate the patients re cell blood counts in order to reduce chance of infection

Increase the patients fiber and water intake to reduce the chance of diarrhea

Monitor the patients protein levels in order to keep blood counts high and stable

Monitor patient for symptoms of GVHD ( Graft-versus-host disease) such as jaundice, abdominal pain, dry or irritated eyes, fatigue, muscle weakness, weight loss, etc

Monitor White Blood cells Counts Monitor patient’s energy intake as well as macronutrients

intake

MONITORING AND EVALUATION

Client History 28 y/o white male, married with 3 children Acute lymphoblastic leukemia (ALL) Admitted to transplant unit for a 10/10 HLA MUD with

myeloablative cyclophosphamide and total body irradiation 1 alcoholic drink daily and smokes ½ pack daily

Anthropometric Data Height: 5’9’’ Weight: 198 lbs BMI: 29.4

Physical Findings Macropapular rash on palms and trunk Grade 2 mucositis in mouth Patient reports feeing fatigued, complains of mouth

pain/discomfort from rash Diarrhea continues with occasional nausea

Vital Signs Temperature: 98.4 Pulse: 83 Blood Pressure: 130/82

ADIME NOTES

Biochemical Data

ADIME NOTES

Food and Nutrition Related History Patient states that usual body weight was 230 lbs Prior to diagnosis and with initial chemo treatment in

2008, patient lost 50 lbs. The next year, patient gained 20 lbs

48-hour recall shows intake prior to admission good and likely meeting >100% of calorie and proteins needs

Comparative Standards Kcal: 1,858.75 kcal/day Protein: Post-op 90-135 g/day Fluid: 2.2-2.9 L/day = 9 (8 oz.) glasses per day

ADIME NOTES

Diagnosis & Intervention PES #1:Altered GI function (NC-1.4) related to chemotherapy and total

body irradiation as evidenced by 3.5 L l iquid stool past 24 hours. Nutrition Rx : Meeting nutritional needs through bypassing the GI tract. Nutrition Intervention : Initiate Parenteral Nutrition (2.2)Dextrose: 571 mL ; D70 ; 400g 1360 KcalsAA: 900 mL ; 15% AA; 135g 540KkcalsIVFE: 200 mL ; 20% IVFE ; 40g 400 Kcals

Total: 2,300 Kcals PES #2: Altered nutrit ion related lab values (WBC, NC-2.2) related to

cancer treatment as evidenced by 2.9 White blood cell count Nutrition Rx : Modify diet to a low microbial diet with high protein,

adequate energy. Nutrition Intervention : This can be done through avoiding

raw/undercooked foods (seafood, eggs, vegetables, undercooked meats, unpeeled fruits or unpasteurized dairy products. This diet wil l reduce the chance of the patient becoming il l while his immune system is weak. Educate the patient on the importance of food safety and how this contributes to the low microbial diet.

ADIME NOTES

Monitor anthropometrics by checking weight, BMI, and waist circumference to prevent weight loss

Evaluate the patients knowledge of the microbial diet and what he should and should not eat when his immune system is suppressed

Evaluate the patients blood counts in order to reduce chance of infection through low blood counts

Increase the patients fiber and water intake to reduce the chance of diarrhea

Monitor the patients protein levels in order to keep blood counts high and stable

Monitor patient for symptoms of GVHD ( Graft-versus-host disease) such as jaundice, abdominal pain, dry or irritated eyes, fatigue, muscle weakness, weight loss, etc

Monitor White Blood cells Counts Monitor patient’s energy intake as well as macronutrient

intake

ADIME NOTES

Nahikian-Nelms, Marcia, and Sara Long. Roth. Medical Nutrition Therapy: A Case Study Approach . Belmont, CA: Wadsworth/Thomson Learning, 4 th ed., copyright 2014. Print.

Internet Resources American Cancer Society: www.cancer.org National Cancer Institute: www.cancer.gov Nutrition Care Manual: www.nutritioncaremanual.org Dietary Guidelines for Americans 2010:

www.dietaryguidelines.gov

REFERENCES