NS490 Unit 9 Gastrostomy to Oral Intake Plan Example

One Can Less Every Time He Eats Enough: A Unit 9 Transition and Discharge Plan From Gastrostomy to Oral Intake After Chemoradiation

[Student Name]

Purdue University Global

NS490: Medical Nutrition Therapy II

Unit 9 Transition and Discharge Plan

[Instructor Name]

[Date]

The patient, his brother and his care team are composite; the head and neck cancer nutrition guideline and the cancer nutrition guideline cited are real.

Part 1: Clinical Summary for the Team

Dennis is 61. He finished seven weeks of radiation with weekly cisplatin for a cancer of the tonsil six weeks ago. A gastrostomy was placed before treatment because his tumor and the planned radiation fields made a long period of poor swallowing likely. During treatment he lost weight steadily as mucositis made eating painful. He now weighs 67 kg, down from 79 kg before treatment, a loss of 12 kg or about 15 percent. His mouth sores have healed, but he has a dry mouth and says most foods taste like cardboard.

His speech-language pathologist completed a swallow study last week. He can safely take soft and bite-sized foods and thin liquids, with a chin tuck for thin liquids, and he is doing swallowing exercises twice a day. He lives with his brother in a second-floor apartment with a refrigerator and a microwave but no working stove. He receives disability benefits and buys his own groceries.

Part 2: Requirements

Energy. For most people with cancer, guidance treats a daily 25 to 30 kcal for each kilogram as the place to begin (Arends et al., 2017). Dennis has lost 15 percent of his weight and has to regain it, so the team works from the higher band of 30 to 35 kcal. At 67 kg that gives 2,010 kcal at the low end and 2,345 kcal at the high end.

Protein. The same guidance asks for more than 1 g for each kilogram, reaching 1.5 g where the patient can manage it (Arends et al., 2017). Using 1.2 g gives 80 g a day for Dennis; using 1.5 g gives 101 g.

Fluid. Roughly 2,000 mL a day covers him, with extra water flushes on hot days because dry mouth makes him sip less than he thinks.

Part 3: Where He Is Now

His regimen is four 250 mL cans of a 1.5 kcal per mL formula by bolus through the gastrostomy, one can at each of four times across the day. Each can gives 375 kcal and about 15 g protein, so the four cans give 1,500 kcal and 60 g protein. A three-day intake record shows about 600 kcal and 20 g protein by mouth, mostly yogurt, scrambled eggs, mashed potatoes and milkshakes. His total, near 2,100 kcal and 80 g protein, sits in the lower part of his energy range and right at the floor of his protein range, with no margin for a bad week.

Part 4: The Taper Rule

One can comes out each time Dennis adds about 375 kcal by mouth, above his starting 600 kcal, for three days in a row, so the tube gives way only as fast as his eating actually grows.

The rule is designed to be followed without arithmetic. Each day he or his brother checks off what he ate on a printed food list that shows the calories for each item already added up in portions he uses. When the daily total passes the next line on the sheet for three days running, the next can is dropped. The order is fixed: the midday can goes first, then the afternoon can, then the morning can. The bedtime can stays last because it protects him overnight when he eats nothing.

Line 1 on the sheet is 975 kcal by mouth, which drops him to three cans. Line 2 is 1,350 kcal, which drops him to two. Line 3 is 1,725 kcal, which drops him to one. Line 4 is 2,100 kcal, which drops the last can, while the tube stays in place.

If his weight falls by more than 1 kg in a week at any point, he goes back up one can and the dietitian is called.

Part 5: Criteria for Removing the Tube

The tube is not removed when the last can is dropped. UK multidisciplinary guidance for head and neck cancer stresses that tube removal follows a team review of intake, weight and swallowing rather than a single number (Talwar et al., 2016). This team's criteria are that Dennis meets at least 2,010 kcal and 80 g protein by mouth, keeps his weight stable for four weeks without any formula, drinks enough to keep his urine pale, and has his swallowing reviewed again by the speech-language pathologist. The physician then decides on removal at a clinic visit.

Part 6: Dry Mouth and Taste Before Texture

After radiation, dry mouth and changed taste often hold back eating more than the swallow itself. Practical guidance for cancer patients supports giving advice on symptoms that limit intake alongside the diet (Muscaritoli et al., 2021). For Dennis this means sipping water with every bite, adding gravy, sauce or melted butter to every solid, choosing cold and moist foods when his mouth is sore, rinsing with a baking soda and salt solution before meals, and trying tart or seasoned foods when everything tastes flat. He is not asked to try harder textures until he can eat soft foods without long pauses.

Part 7: Who Owns Each Piece

The speech-language pathologist owns texture advancement and his exercises. The dietitian owns the taper sheet, weight checks and the food list. The physician owns tube removal. A case manager owns formula supply and his benefits, including whether formula is covered and whether he qualifies for nutrition assistance. Dennis and his brother own daily feeding and the check-off sheet.

Part 8: Household Section, Written for Dennis and His Brother

Your daily schedule. Morning can at 8, midday can at 12, afternoon can at 4 and bedtime can at 9. Eat something small between cans, even if it is only half a cup of yogurt.

Storing formula. Keep unopened cans in a cool cupboard. Once a can is opened, cover it and keep it in the refrigerator, and use it within 24 hours.

Before and after each feed. Wash your hands. Flush the tube with 60 mL of water before and after each can, and with 30 mL after any medicine. Rinse the syringe in warm soapy water, let it air dry, and replace it each week.

If the tube is blocked, flush gently with warm water. Do not push hard or put anything sharp inside. If it will not clear, call the clinic. If the tube comes out, cover the site with clean gauze and call the clinic right away, because the opening can start to close within hours.

Foods that need only a microwave. Scrambled eggs, oatmeal made with whole milk, mashed potatoes with butter, canned soups thickened with instant potatoes, soft canned fish with mayonnaise, cottage cheese, pudding, ripe bananas, and milkshakes made with ice cream and milk powder. Most cost little, keep well, and are soft and moist. Stores sell powdered milk in large boxes, and a spoonful stirred into soup or oatmeal adds protein without adding volume.

Who to call. The formula supplier for deliveries, the clinic for the tube, problems with feeding or weight loss, and the speech therapist for swallowing problems. Keep these numbers on the refrigerator.

Part 9: Monitoring

Weight is checked weekly at home on the same scale, after his morning can, and reported to the dietitian. The check-off sheet is reviewed at every clinic visit. The dietitian calls each week for the first month after discharge. Signs that should prompt a call include coughing or choking while eating, a fever, weight loss of more than 1 kg in a week, or a week in which he cannot reach the line he last passed.

References

Arends, J., Bachmann, P., Baracos, V., Barthelemy, N., Bertz, H., Bozzetti, F., Fearon, K., Hütterer, E., Isenring, E., Kaasa, S., Krznaric, Z., Laird, B., Larsson, M., Laviano, A., Mühlebach, S., Muscaritoli, M., Oldervoll, L., Ravasco, P., Solheim, T., . . . Preiser, J.-C. (2017). ESPEN guidelines on nutrition in cancer patients. Clinical Nutrition, 36(1), 11-48. https://doi.org/10.1016/j.clnu.2016.07.015

Muscaritoli, M., Arends, J., Bachmann, P., Baracos, V., Barthelemy, N., Bertz, H., Bozzetti, F., Hütterer, E., Isenring, E., Kaasa, S., Krznaric, Z., Laird, B., Larsson, M., Laviano, A., Mühlebach, S., Oldervoll, L., Ravasco, P., Solheim, T. S., Strasser, F., . . . Bischoff, S. C. (2021). ESPEN practical guideline: Clinical nutrition in cancer. Clinical Nutrition, 40(5), 2898-2913. https://doi.org/10.1016/j.clnu.2021.02.005

Talwar, B., Donnelly, R., Skelly, R., & Donaldson, M. (2016). Nutritional management in head and neck cancer: United Kingdom National Multidisciplinary Guidelines. The Journal of Laryngology and Otology, 130(S2), S32-S40. https://doi.org/10.1017/S0022215116000402