Knowledge Activity: Dietetics Case Study – Partial Gastrectomy

Questions
1.​ W
​ hat type of surgery did Greta have?

- A partial gastrectomy

2.​ C
​ an you explain why Greta needed this type of surgery?

- Greta had this surgery because she had gastric cancer and the cancer cells were too
frequent to be taken care of through chemotherapy alone.

3.​ ​According to the Admission Summary, there was no apparent lymph involvement and
pathology report confirms a stage T1 N0 M0 Stage 1A carcinoma of the gastric mucosa. Explain
what this means.

- T1: submucosa
- NO, MO: no spreading has occurred to the lymph nodes or other organs.
- 1A: This means that the carcinoma has spread to the inner walls of the stomach, but has
not yet spread to any other organs.

4.​ C
​ an you explain why Greta has a past medical history of Pernicious Anemia?

- Greta has cancer in her stomach and in the stomach, there is a process called an intrinsic
factor that produces (trace amounts) and absorbs much of the body’s B12. Without it, she
would likely develop a B12 based deficiency called pernicious anemia.

5.​ W
​ hat is Greta’s height, weight and BMI?

- Greta is 163cm, 55kg, and her BMI is 20.7

6.​ W
​ hat are her estimated nutrient needs (kcals/protein/fluids)?

- Calories: at least ​1,600​kcals for her age and gender

- Mifflin St. Jeor: (10 × 55kg) + (6.25 × 163cm) - (5 ×76) - 161 =
- 550 + 1,019 - 360 - 161 = 1,048 x 1.2AF = 1,258kcals
- Protein: (.8g/kg) .8 x 55 = ​44g ​(i would recommend an increase to about 60g due to her
surgery and need for internal healing)
- Fluid: ​1.5-2L​ of fluid per day

7.​ W
​ hat type of diet has been ordered for Greta?

- Clear liquid diet

8.​ ​Do you agree or disagree with her diet order? What nutrition prescription would you
recommend?

- I agree with this diet. In the details of this order, it specifies to advance to a full liquid
diet as tolerated. The reason Greta was put on a clear liquid diet is due to ehr gastric
surgery, which is protocol to help the procedure run smoothly. It is also important to have
Greta eased back into solid foods because of her new (lessened) stomach surface area.
She is healing and needs to nourish herself in order to do so, but it is essential that she
avoids over consuming or consuming the wrong foods at the risk of breaking her sutures,
stretching her healing skin, or getting an infection.

9.​ W
​ hat are possible side effects Greta may experience after surgery?

- Greta may experience dumping syndrome, diarrhea, acid reflux, internal bleeding, nausea
/ vomiting, and infections

10.​ ​What are your nutritional concerns for Greta?

- I am worried that she will not be consuming enough after her surgery and will not get the
proper nutrients that she needs to heal herself. She is already nauseous from the surgery
and her current medications, and on top of that, she will be starting chemotherapy again
when she is “well enough” after her surgery.

11.​ ​What questions would you like to ask Greta when you interview her?

- Have you had a decrease in appetite lately? What foods do you normally like to
consume? How frequently do you eat each day? Are you able to measure portion sizes
(new or old ones in regards to your new stomach)?

12.​ ​Using Standardized Language, select 2 possible problem statements from the Intake, Clinical
and Behavioral Domains.

- Intake: Increased nutrient need (B12), predicted inadequate energy intake

- Clinical: Altered gastrointestinal function*, impaired nutrient utilization
- Behavioral: impaired ability to prepare foods/meals, food and nutrition related knowledge
deficit

13.​ ​What type of nutrition education do you think would be best for Greta?

- Nutrition education in the form of food models to demonstrate proper portion sizes to
ease greta back into eating “normally”. It is important to explain the risks of not
following this diet. It also might be helpful to send meal plans home with her as well as a
list of foods she should not eat for the next few months until she is healed.
Knowledge Activity: Dietetics Case Study – Bariatric Surgery
Questions
1.​ ​Define what type of procedure Malcom has just undergone. The procedure is found
on the Overview tab of the chart under Encounter Status.
- Malcolm has undergone an elective laparoscopic gastric banding procedure for
morbid obesity one day ago.

2.​ ​Compare and contrast the procedure Malcolm has just undergone to other types of
bariatric surgeries. Review the Bariatric Surgery resource that accompanies this activity.
- The laparoscopic gastric banding is specifically a weight loss surgery, apart from
some of the other bariatric surgeries. An adjustable band is placed around the
stomach that can be tightened to separate the stomach into two parts which
restricts the amount of food that is able to be put into the stomach. Other
procedures involve removing parts of the stomach or making it inaccessible to
food that comes in.

3.​ ​What are the adult criteria for consideration as a candidate for bariatric surgery?
Review the Bariatric Surgery resource that accompanies this activity. After reviewing
Malcom’s chart, determine the criteria that allow him to qualify for surgery.
- Your body mass index (BMI) is 40 or higher (extreme obesity).
- Your BMI is 35 to 39.9 (obesity), and you have a serious weight-related health
problem, such as type 2 diabetes, high blood pressure or severe sleep apnea. In
some cases, you may qualify for certain types of weight-loss surgery if your BMI
is 30 to 34 and you have serious weight-related health problems.
- Malcom had a BMI of 57 which is well over the required 40+. He has tried to lose
weight multiple times on his own and has failed.

4.​ ​List at least 8 health risks of class III obesity. Review the Bariatric Surgery resource
that accompanies this activity.
- Hypertension, heart disease, cancer, diabetes, nephritis/nephrotic
syndrome/nephrosis, chronic lower respiratory disease, influenza and pneumonia

5.​ ​What Nutrition Assessment information do you need to gather to determine the
nutrition problem? Review the Academy Position Paper resource that accompanies this
activity.
- I would need to determine the patient’s emotional relationship with food and how
their quality of life is in general. It would also be helpful to know the
socioeconomic status of the patient and how their ability to cook is (and where it
 came from maybe). It is important to know who buys the food and who cooks it.
Lastly, I would need to know about the client and family’s medical history
(surgeries, eating disorders, and diseases).

6.​ ​Labs have been ordered but are not yet resulted. Can you still complete a Nutrition
Assessment? Review the Academy Position Paper resource that accompanies this
activity.
- I would need a glucose, endocrine, and lipid profile prior to completing the
assessment. The cause of the nutritional issues cannot be determined without this
piece of information and therefore, a diagnosis cannot be given then as well.

7.​ ​What are Malcolm’s energy, protein and fluid needs at this time? Explain what
method you used to determine your answer.
- Ideal body weight: 6lbs per inch over 5ft + 106
- (5’8) 6 x 8 + 106 = 154lbs
- Adjusted ideal body weight: 376lbs - 154 = 222 x .25 = 55.5 + 154 = ​209.5lbs
- Mifflin St. Jeor: (10 x 209.5lbs) + (6.25 x 68in) - (5 x 35) + 5 =
- 2,095 + 425 - 175 + 5 = ​2,350 calories
- AF: 2,095 x 1.200 (sedentary) = 2,514 calories
- Protein: 2.5g/kg IBW = 2.5 x 70kg = ​175g
- Fluid: 1mL fluid per kcal = ​2.3L

8.​ ​What is Malcolm’s current nutrition prescription (diet order) at this time?
- Clear liquids due to his recent surgery and need to slowly adjust to his new
stomach alterations.

9.​ ​What questions do you think you need to ask Malcolm to help determine the nutrition
problem? Review the Academy Position Paper resource that accompanies this activity.
- Who does the grocery shopping and who does the cooking? What emotions do
you feel when you notice yourself eating a lot? Do you exercise regularly? What
specific types of foods do you eat most often? What foods do you consider
“healthy”? What diets have you tried in the past? Why do you think they didnt
work?

10.​ ​What lifestyle changes would you view as a priority for Malcolm?
- Making sure he chooses the right foods and exercises as much as he can (given
his current state). Portion control is essential as well, not only for his short term
recovery but also in the future to keep the weight off.
11.​ ​Using standardized language, what are possible problem statements? Pick the best
one and write a PES.
- Predicted excessive energy intake related to morbid obesity and inability to lose
weight as evidenced by current BMI of 57 and obesity diagnosis for the past 15
years.

12.​ ​Based on your PES, what is an appropriate Nutrition Intervention? See table below
from Academy Nutrition Care Manual table.
- Nutrition counseling: Instruct the patient on self-monitoring, for instance, how to
graph weight changes over time. Patients may benefit from keeping a food diary.
- Consider the following techniques/strategies: • Nutrition counseling based on
self-monitoring strategy
13.​ ​What resources are available to help you determine the appropriate Nutrition
Intervention?
- The academy of nutrition and dietetics, hospital procedure / protocol manual, and
studies on bariatric surgery diet successes

14.​ ​Why is an interprofessional approach to weight loss important to help Malcolm

succeed?
- Malcolm cannot lose weight through diet alone. In this case he needed surgery to
become a healthy weight again. This calls for the help of doctors and surgeons to
do the procedure and monitor his recovery. He will also need the help of nurses
and pharmacists to help his healing process as well as physical therapists to help
him get back on his feet again safely.

15.​ ​What role can an outpatient dietitian play postoperatively regarding Malcolm’s
nutritional status?
- A dietitian can ensure he is getting enough nutrients and supplementing properly
to compensate for his altered digestive function. They can also closely monitor his
weight loss to make sure he is losing it at a healthy rate. Lastly, they can also
make sure he is eating enough for his body to heal, but not too much to stretch the
gastric band.
 Shawn Callahan Scene 1 (Crohn's Disease Pre-op loop ileostomy)

ADIME Note:

Assessment:
Admitting complaint: Recent exacerbation from non-resolving colitis resulting in dehydration
and severe pain.

Past medical history: Shawn was diagnosed with Crohn's disease at age 19 following a year of
non-specific symptoms including joint pain and swelling of his hands and feet, stomach pains
and fatigue. Crohn's was diagnosed through an upper G.I. and follow through which showed
strictures and narrowing in the small intestine indicative of the disease. Since diagnosis, he has
had a number of flare-ups with 4 small bowel resections and a few minor procedures for various
complications related to Crohn's. He has been admitted today via his gastroenterologist with joint
pain and swelling, dehydration and severe pain secondary to exacerbated and persistent colitis.
He denies history of recent international travel, consumption of undercooked or raw foods, or
recent antibiotics use for an unrelated illness.

Surgeries: Four small bowel resections and a number of minor procedures for various
complications related to Crohn's over the last 26 years.

Injuries: Non-contributory

Family History: Father and Paternal grandmother were known to have nervous stomachs. Both
died of other causes in early middle age. Grandmother died of brain cancer and father in a MVA.
No other autoimmune disorders known in family members. Patient does have two young children
who do not have symptoms of Crohn's.

Current medications:
Metrol dose pack taper (methylprednisolone) - He has maxed out the recommended duration of
steroid treatment
Metronidozole 1 gm per day
Loperamide (2-4 mg) prn for diarrhea, up to 4 times daily

Exam: 99.8, 102, 21, 149/76; weight: 165, height: 5'8", BMI: 25.1

Diagnosis:
Impaired nutrient utilization related to Crohn’s disease diagnosis as evidenced by severe pain,
dehydration and apparent inflammation of the intestines.
Intervention:
Make patient NPO (should decrease the pain and inflammation)

Educate patient on diet procedures before and after surgery (TPN for about two weeks) and how
the surgery will affect his ability to absorb and utilize nutrients.

Monitoring and Evaluation:

Follow up with RDN post-operatively to discuss TPN requirements and make adjustments to
diet.

Nutrition Prescription:
NPO prior to surgery.*

Calories: Mifflin St. Jeor

- (10 x 165lbs) + (6.25 x 68in) - (5 x 45) + 5 =
- 1,650 + 425- 225 + 5 = 1,855 calories x 1.2AF = 2,226 or ​2,200 ​calories
Protein: (1-1.5g/kg) 75kg x 1.5 = 112.5g ​(100g)
Fluid: ​2.2L

75kg, 68”, 45yo

 Shawn Callahan Scene 2 (Crohn's Disease Post-op loop ileostomy)

ADIME Note:

Assessment:
Admitting complaint: Recent exacerbation from non-resolving colitis resulting in dehydration
and severe pain.

Past medical history: Shawn was diagnosed with Crohn's disease at age 19 following a year of
non-specific symptoms including joint pain and swelling of his hands and feet, stomach pains
and fatigue. Crohn's was diagnosed through an upper G.I. and follow through which showed
strictures and narrowing in the small intestine indicative of the disease. Since diagnosis, he has
had a number of flare-ups with 4 small bowel resections and a few minor procedures for various
complications related to Crohn's. He has been admitted today via his gastroenterologist with joint
pain and swelling, dehydration and severe pain secondary to exacerbated and persistent colitis.
He denies history of recent international travel, consumption of undercooked or raw foods, or
recent antibiotics use for an unrelated illness.

Surgeries: Four small bowel resections and a number of minor procedures for various
complications related to Crohn's over the last 26 years.

Injuries: Non-contributory

Family History: Father and Paternal grandmother were known to have nervous stomachs. Both
died of other causes in early middle age. Grandmother died of brain cancer and father in a MVA.
No other autoimmune disorders known in family members. Patient does have two young children
who do not have symptoms of Crohn's.

Current medications:
Metrol dose pack taper (methylprednisolone) - He has maxed out the recommended duration of
steroid treatment
Metronidozole 1 gm per day
Loperamide (2-4 mg) prn for diarrhea, up to 4 times daily

Exam: 99.8, 102, 21, 149/76; weight: 165, height: 5'8", BMI: 25.1

Diagnosis:
Altered gastrointestinal function related to newly placed ileostomy as evidenced by physical
change in patient’s anatomy from surgery.
Intervention:
Low fiber diet
Increased protein (for healing)
Rehydration therapy
NPO until further notice, feeding through TPN (peripheral IV catheter) to allow the GI tract to
heal from surgery. Use for less than 3 weeks.

Calories:
Mifflin St. Jeor: (10 x 165lbs) + (6.25 x 68in) - (5 x 45) + 5 =
- 1,650 + 425- 225 + 5 = 1,855 calories x 1.2AF = 2,226 or ​2,200 calories
Protein: (1-1.5g/kg) 75kg x 1.5 = 112.5g ​(100g)
Fluid​: 2.2L

Educate the patient on how he can manage his Crohns through a diet low in poorly tolerated
foods. It is also important to educate the patient on how to care for his new stoma and what foods
to consume to ease his body into this new change. Discuss in detail the importance of proper
hydration and how he can achieve that with his condition.

Monitoring and Evaluation:

Follow up with RDN in 24 hours to ensure TPN is accepted well and the patient is healing.

Nutrition Prescription:
Infuse TPN at 90mL/hr for 24 hours to get 2,160mL, 2.2L fluid, and electrolyte replacement.

Max 75g / .2 = 375mL of 20%

375 x 2 = ​750kcals​ ​liposyn

100g / .085g/mL = ​1,176mL of aminosyn

d30=.3g/mL
D x wt x min/day / 1,000mg =
.003 x 75kg x 1,440min = 324 / .3 = ​1,080mg d30
1080 / 2,000mL x 250 x 4.1 = 553kcals CHO
1,080 x 2 = 2160 / 24 =​ 90mL per hour goal rate
90 x 24 =​ 2,160mL

2160 / 2 = 1080 x .3 = 324 x 3.4kcal = 1,101.6 CHO

1080 x 1 = 1,080 x 4= 4,320mL
TPN 2 in 1 D30, 8.5% aminosyn at 90mL/hr with 375mL 20% liposyn.
3 WEEKS POST SURGERY: Regular, low fibre diet consisting of 2,200 calories, 100 grams of
protein, 2L fluid.