Brandon Fraser

4/21/17
NTR 417
Nutrition Care Plan
!
!
SOCIAL HISTORY : Annette Woodside is a 52 year old woman who is married with two
children and lives in East Greenbush, NY. Annette and her husband currently live alone in a
middle-class rural area. The son and daughter were both adopted from different mothers and are
currently away from home at college. Annette works in sales at Pella Windows and can be
classified as upper-middle class. Given her economical status, Annette has never been in
financial hardship. Because Annette is currently going through chemotherapy for breast cancer,
she is currently out of work. Her husband is the full source of income at this time. Annettes
older sister, Suzette , is her main caretaker. Suzette lives only 5 minutes from Annette and works
from home, so this is very manageable for her.
!
Nutritional Implications: Due to Annette being required to follow a strict diet while going
through breast cancer, Suzette has attended every doctors appointment and treatment session to
understand the restrictions and limitations. Suzette is the main food preparer for Annette, due to
Annette being bedridden and nauseous a majority of the time. Suzette is required to adhere to the
diet plan, but also force her sister to eat to prevent weight loss.
!
MEDICAL HISTORY : Annette has breast cancer, where she was diagnosed in September,
2016. Annette has a history of PCOS, or polycystic ovarian syndrome. PCOS is the most
common cause of female infertility. This was diagnosed after Annette tried to conceive multiple
times, and failing. She has a history of depression, which has been a prominent disease in the
family. Most recently, she was diagnosed with breast cancer in September of 2016. It is
hypothesized that the breast cancer was caused from the hormonal issues, weight gain, but also
genetics. Annettes mother also had breast cancer. Due to the chemotherapy and medicines she is
taking, she is also experiencing acid reflux.

Nutritional Implications: Annettes current medical problems will adversely affect her
nutritional status, as well as require adherence to a strict diet. Because of the chemotherapy,
Annette is experiencing gastrointestinal problems and diarrhea. Due to the diarrhea, Annettes
water intake should be increased to accommodate for the water lost through stools. Annette will
also need probiotics to restore the good bacteria that is being destroyed or lost through treatment.
!
DIET HISTORY : Annette is currently consuming a low sugar, dairy-free diet. Annette states that
she has no appetite most of the time due to nausea, but when she does eat its sporadic. According
to the 3 day food recall she recorded, her diet provides an average of 1500 calories and 77 grams
of protein if completely consumed. She has eliminated caffeine and alcohol to prevent acid
production and prevent acid reflux. During this time, Annette has also implemented the
elimination diet to determine what causes her acid reflux.
!
Nutritional Implications: On days surrounding each chemotherapy treatment, Annette finds it
hard to eat due to nausea, excessive diarrhea, and being bedridden from pain. She mentions that
due to her decreased desire and palatability of foods, she forces herself to eat plain oatmeal due
to its ability to satiate her. However, a few days after chemo treatment, which is also when she
recorded the 3 day recall, her diet is still low in calories. According to super tracker, her diet is
adequate in protein, carbohydrates, fiber, and most vitamins. It is deficient in calories and
Vitamin D. Annette will need to supplement Vitamin D into her diet.
!
!
MEDICATIONS:
!
!
Dexamethasone 4mg: is a corticosteroid taken the day prior to chemo treatments and the day of
to help reduce an allergic reaction to the chemotherapy drugs. It prevents the release of
substances in the body that cause inflammation.
!
Nutritional Implications : Side effects include fluid retention, sleep problems, acne,
headache, nausea, and vomiting. Drugs that interact with this medication include aspirin, birth
control pills, diuretics, insulin , and any NSAIDS. Annette is experiencing sleep problems,
headache and nausea from this medication.
!
Ativan .5mg: is a sedative that belongs to a group of drugs called but benzodiazepines. This drug
affects the chemicals in the brain that may be unbalanced in people with anxiety. It is also used
during chemotherapy for nausea. It is taken at night due to most cancer patients experiencing
headaches and nausea upon waking. This drug helps prevent headaches and nausea in the
morning, while also helping the patient sleep by relaxing them.
!
Nutritional Implications: Side effects include dizziness, drowsiness, and weakness. Ativan
can be taken with or without food. Annette is not experiencing any side effects directly from this
medication. This drug helps Annette sleep and prevents headaches upon waking.
!
!
Omeprazole 40mg: is a proton pump inhibitors used to treat symptoms of gastroesophageal
reflux disease (GERD) and other conditions caused by excess stomach acid. Taken Daily and
was recently increased to one tablet, twice daily.
!
Nutritional Implications: this drug is not for immediate relief of heartburn conditions. This
drug should be taken 1 hour prior to eating to maximize absorption. Common side effects include
stomach pain and gas, nausea, vomiting , headache. Annette finds this drug to be effective in
preventing acid reflux, and does not experience any side effects.
!
Herceptin is a monocional antibody which targets cancer cells more precisely than chemotherapy
and used with breast cancer patients where their cancer is HER 2 positive. Received every week
delivered by port.
!
Nutritional Implications: Side effects include fever, chills , muscle aches, and nausea. Other
drugs may interact with this drug, including prescription and over-the-counter medicines,
vitamins, and herbal products.
!
Taxotere is a chemotherapy drug given to prevent cancer cells from dividing and growing and
can cause cancer cells to shrink and die. Given by port every 3rd week for 6 treatments.
!
Nutritional Implications: Side effects of this medication include nausea, mouth sores, hair
loss, nail changes, fluid retention, peripheral neuropathy, and low red blood cell counts. Alcohol
should be completely avoided. Do not take aspirin containing products or herbal products as it
may interact with this medication. Annette experiencing hair loss, nail changes, numbness , and
nausea.
!
Carboplatin is a chemotherapy drug given to prevent cancer cells from dividing and growing and
can cause cancer cells to shrink and die. Given by port every 3rd week for 6 treatments.
!
Nutritional Implications : Low blood counts ( including white blood cells, red blood cells,
and platelets) occur in greater than 30% of patients taking this medication. Diarrhea , nausea,
vomiting, and hair loss are also common. Abnormal magnesium levels in blood are common. Do
not take aspirin or any aspirin containing drugs as it might interfere with this medication. Annette
is experiencing diarrhea and hair loss.
!
Zoloft 50mg: is an antidepressant in a group of drugs called selective serotonin re-uptake
inhibitors (SSRIs). It is used to treat but not limited to: depression, anxiety, OCD, PTSD.
!
Nutritional Implications : Zoloft may be taken with or without food.
!
Imodium 125mg : Imodium slows the rythmym of digestion so the small intestines have more
time to absorb the fluid and nutrients eaten. It is also used to remove the amount of stool.
!
Nutritional Implications : Drink plenty of water while taking this medicine as it could take up
to 48 hours for symptoms to subside. Avoid drinking tonic water while taking this medication.
Side effects include constipation and stomach discomfort. Annette is not experiencing
constipation but is having stomach discomfort. This medication seems to work as intended for
Annette and alleviate her GI issues.
!
!
PATHOPHYSIOLOGY:
!
Annettes current problem is stage 2 breast cancer. Despite the fact that her mother had breast
cancer and she already had a genetic predisposition to this disease, there were other factors that
were believed to have contributed. According to Annette, she believes a gain in weight before
she was diagnosed, long going hormonal issues, and genetics all contributed to her getting breast
cancer. The pathophysiology of breast cancer will be discussed below.
!
Cancer involves the abnormal division and reproduction of cells that can spread throughout the
entire body(Mahan and Raymond, 2017). More specifically, breast cancer occurs when cells start
to form a tumor in either of the female breasts and can be seen on an x-ray or felt as a lump.
Although breast cancer is more common in women, men can also get it. Breast cancer is much
more prevalent in developed nations in comparison to developing ones. The cause of breast
cancer is not fully known, but there are a number of risk factors that have been identified.
According to Balentine, cancerous breast cells caused from DNA mutations on the BRCA1 and
BRCA2 genes are inherited, but most DNA changes related to breast cells are acquired during
ones life.( Balentine, 2016) Some of the big contributors to breast cancer risk aside from
genetics include old age, menstruation at a young age, denser breast tissue, obesity, tobacco and
alcohol use.(Balentine, 2016) Kelsey et al. (2014) reported that body weight throughout
childhood should be at the lower end of the normal BMI as excessive weight in adolescence has
been correlated with increased risk of cancer in adulthood. The severity of breast cancer is
categorized into four stages. Stage I describes invasive breast cancer where cancer cells are
invading normal breast tissue, and localized. Stage II is when the tumor in the breasts is greater
than 2cm or the cancer has spread to 1-3 surrounding lymph nodes. Stage III is when the tumor is
greater than 5cm or found in 4-9 lymph nodes. The breasts may appear red and swollen at this
stage. Stage IV describes invasive breast cancer when it has spread beyond the breasts and
nearby lymph nodes to other organs of the body such as the lungs, skin, bones, or brain.
(Abeloff,Wolff,Weber, 2008)) Annette Woodside has stage two breast cancer, where there is a
small, localized, tumor in her breast.
!
Once diagnosed, treating breast cancer depends on the progression of the cancerous cells.
Treatment options include surgeries to remove as much of the cancer as possible or for more
advanced breast cancer, chemotherapy. Surgery to remove parts of the breasts or the entire breast
tissue is known as a mastectomy. Chemotherapy is treatment with cancer killing drugs that may
be given intravenously or by mouth. These drugs travel through blood stream to reach cancer
cells in most parts of the body.(American Cancer Society, 2016) It is not uncommon for breast
cancer patents to go through chemotherapy after a mastectomy to kill off any cancerous cells that
may have been left behind. In most cases, chemotherapy is most effective when a combination
of drugs is used. For example, the drugs Annette is currently taking for chemotherapy are
Docetaxel, Carboplatin, and Trastuzumad. These drugs are given intravenously in cycles
followed by periods of rest. Annette is following this same protocol as she had a complete
mastectomy first, followed by bi-weekly treatments of chemotherapy.

In regards to nutritional therapy for breast cancer, there are a number of restrictions and
recommendations one can implement to help prevent further growth and potentially contribute to
remission. According to Mahan and Raymond, a diet containing various antioxidant and phenolic
compounds found in tea, coffee, and fruits and vegetables provides anti carcinogenic agents.
( Mahan and Raymond, 2016) Bender et al. (2013) says eating a plant based diet may aid in
cancer prevention by functioning as cancer inhibitors through anti-inflammatory mechanisms
and changes in gene expression and hormone activity. A low-fat, plant-based diet , is also
recommended. The Womens Intervention Nutrition Study found that a reduced fat intake
improves relapse-free survival by 24% in women with breast cancer compared to women
following a standard diet. ( Helwick,2017) Along with a low-fat diet, a plant-based diet is also
recommended for breast cancer patients. Eating a plant based diet also goes hand in hand with a
decreased risk of obesity due to greater fiber intake and more satiating foods. A plant based diet
would also eliminate nitrate containing foods that are commonly found in processed meats .
Nitrates are use as a preservative but can be readily reduced to nitrites in the body which known
to form carcinogens.( Mahan and Raymond,2016) In order to get enough protein, soy protein is
the best option for a plant based diet. Although the use of soy protein is controversial for women
with breast cancer, diets contain modest amounts of soy have shown to protect against breast
cancer.(ACS,2012) All in all, while going through treatment such as chemotherapy or recovering
from surgery, a nutrient rich diet is going to be crucial in the recovery process by staying strong,
providing energy, reducing fatigue, and managing weight.

Although it may seem like more, according to the American Cancer Society, only 5-10% of
breast cancers are thought to be hereditary. The majority of breast cancer is caused by lifestyle
and eating behaviors. Therefore, the best way to decrease the risk of developing breast cancer is
prevention. Preventative measures include keeping weight in check , being physically active,
eating fruits and vegetables, avoiding excessive alcohol intake , and not smoking. Lastly, being
physically active is a critical component of weight management and energy balance. According
to the Nutrition and Physical Activity Guidelines for Cancer Prevention, a minimum of 150
minutes per week of moderate activity or a minimum of 75 minutes of vigorous activity is
recommended.( Kushi et al, 2011)
!
!
!
ASSESSMENT:
!
!
!
Annettes medications and chemotherapy treatments for breast cancer can easily impact her
nutritional status. Her excessive diarrhea and loss of appetite puts her at risk of becoming
dehydrated, but also malnourished. Inadequate nutrition can then prevent her body from fully
recovering and providing the nutrients she needs while going through treatment. Annette requires
part time care to cook and fulfill her dietary recommendations on days she is feeling lethargic
and immobile. This is something her sister, Suzette , can do.
!
Annettes estimated energy needs based on indirect calorimetry for non ambulatory cancer
patients are 2190 calories and her estimated protein needs ( based on 1.2gm/kg of BW) for
patients undergoing treatment is 87 grams. Her current diet provides an average of 1490 calories
and 77 grams of protein. This does not meet her requirements for calories or protein. This
inadequate energy intake related to nausea and a loss of appetite is evidenced by her 3 day food
recall. Nutrition education may be needed for her caretaker, Suzette, to teach her how to increase
protein and calories in meals, while following her specific diet.
!
Annette is currently 16lbs lower than she was at the start of her treatment. This weight loss was
voluntary by changing her diet, walking 5 times per week and suggested due to obesity being a
great contributor to cancer cells. She is currently 162lbs. However, Annette has been losing
weight at a rapid pace due to the chemo treatments as well. This could result in inadequate fluid
intake related to uncontrolled diarrhea from chemotherapy and other drugs as evidenced by poor
skin turgor, dizziness, nausea, and thirst. Annettes current fluid requirements are 1ml/kcal of
estimated needs. This would mean she needs 2190ml per day, or 74 fluid ounces. She must also
consider adding in additional water when she experiences diarrhea to accommodate for the fluid
lost through stools.
!
!
!
INTERVENTION: Provide 2190 calories and 87 grams of protein per day
Provide 2190ml of fluid( water ) per day
Collaborate with caretaker : Educate Suzette on increasing protein and calories in snacks and
foods throughout day.
Monitor weight for nutrition and fluid improvements.
!
MONITORING AND EVALUATION:
!
Short term goals
!
1.) Increase water intake to 74oz a day or 1ml/kcal of estimated needs or more if diarrhea
occurs.
!
2.) Increase snacking of higher protein, low fat foods, to reach protein goal.
!
3.) Add in more complex carbohydrates to reach total calorie goal.
!
!
Long term goals
!
1.) Prevent further weight loss, keep weight stable +/- 2% of current weight.
!
2.) Prevent cancer from spreading further by monitoring diet and continuing treatment.