This patient was prescribed several medications during his hospital stay that have important nutritional implications: - Antibiotics like Ciprofloxacin can decrease absorption of calcium and vitamins/minerals if taken with dairy. This patient did not report any related side effects. - Anticoagulants like Heparin and Warfarin require monitoring vitamin K intake, as high or inconsistent vitamin K can decrease their effectiveness in preventing clots. Changes in vitamin K intake could explain this patient's fluctuating electrolytes. - Pain medications like Fentanyl can cause nausea and vomiting, which may decrease oral intake and nutritional status if prolonged. This patient did experience decreased appetite prior to admission. - Heart medications like Met

1. Benedictine University
Dietetic Internship Program
CASE STUDY ASSIGNMENT 2
For Clinical and LTC/Sub Acute Rotation and NTR 622
Objective: This project allows the Dietetic Intern to exhibit his/her ability to seek,
comprehend, analyze, apply, and integrate essential data into a comprehensive medical nutrition
therapy plan of care, which views the patient/client as a whole. The assignment also provided
the intern with experience in application of principles of all steps in the Nutrition Care Process.
Instructions:
 Use this template to complete your assignment. The template is designed to incorporate
the steps included in the Nutrition Care Process (NCP). You may add rows and additional
data to the template as appropriate.
 Make sure to type your assignment.
 Make yourself a copy of your completed case, as the original will not be returned to you
 It is highly recommended to share drafts of your case study with site preceptor(s) and the
DI Director prior to giving a case study presentation.
 Include a table of all references cited. A minimum of 5 references must be used to
complete the case study. One reference must be a current research article related to one or
more aspects related to your case study presentation. Use the format of: Guidelines for
journal authors, J Am Diet Assoc. The guidelines are found in the January issue yearly.
 The Case study is to be presented to the dietitians in both written and verbal format.
 A written copy of the case study report must be submitted to the Dietetic Internship
Director, and your site preceptor(s), as they request.
 All Dietitians attending the presentation are to complete the Presentation Evaluation
Form – prior to your presentation, be certain to copy one form per dietitian expected to
be attend the education session.
Prior to Beginning your report, complete the following:
 Review the patient/client medical record (computer and/or paper versions)
 Conduct an in depth interview and/or diet history (as appropriate)
 Never complete an assessment without visiting your patient and completing a physical
assessment and/or interview.
 Complete a Care Plan Form (You may use BU’s form or the site’s form)
o ATTACH a copy of your care plan to your report

2. NCP Step 1: Nutrition Assessment
Patient Profile
Practice Setting in which you are assessing
this patient/client
Clinical – Intensive Care Unit to Telemetry Floor
Age 85 years old
Gender Male
Race African American
Relevant personal data (e.g. does not speak
English, marital status, lives in a nursing
home, SES etc.)
Father to 11 children who are all actively involved in
his treatment and recovery
Slightly deaf (do not need to talk louder, just closer)
Symptoms/complaints Abdominal pain
CURRENT Medical Conditions/Diagnoses Gastric Cancer
PAST Medical Conditions/Diagnoses Gastric Cancer, HTN, arthritis
Medical Test(s) conducted or planned Daily lab data, human albumin IV, EKG, rhythm
strip
Medical procedure(s) conducted or planned Total gastrectomy, esophagealjejunostomy,
enteroenterostomy
Epidural
Anthropometric Data:
Indicator Value for the patient/client Assessment of patient/client value
Height 167 cm 66 in ---
Weight 79 kg 174lb ---
Weight change 4 # in 1 month ---
UBW 77kg 170lb ---
IBW 71kg 156.2# Upper 10% BMI
% IBW 111% Within Normal Limits
BMI 28.3 Overweight BMI
Adjusted Body Weight --- ---
Patient Weight Goal Maintain current body wt ---
Food/Nutrition RelatedHistory
Food Allergies NKFA
Chewing and/or Dental Problems N/A
Swallowing Problems N/A
Bowel Habits/Problems Occasional stomach pain d/t gastric cancer
Recent Changes in Eating Habits Decreased appetite 1 week PTA d/t gastric pain
Current Appetite Decreased appetite PTA, normally good appetite
Food Preferences Regular diet w/ specific preferences for greens,
bananas, fatty/fried foods (fried meats, starches,
bacon, etc.)
Nutrient Malabsorption Problems? None PTA
N/V/D Occasional of all three d/t gastric cancer
Past Diet Prescriptions Low sodium diet
Past Diet Instructions Low sodium diet

3. 24 – Hour Recall
Meal Type of Food Cooking Method Portion
First Meal of Day --- --- ---
Snack 1 banana Home prepared Medium sized
Second Meal of Day Turkey Sandwich,
white bread, cheese,
lettuce, tomato,
mayonnaise
Home prepared 2 slices commercial sized
bread, 3-4 oz. pre-sliced deli
turkey, 1 lettuce leaf, 2 slices
tomato, 2 Tbsp. mayonnaise.
Snack --- --- ---
Third Meal of Day Spaghetti w/ meat
sauce, milk, 1 slice
Texas toast garlic
bread
Home prepared
(Texas toast was
store bought
frozen)
1 cup cooked spaghetti (w/
salt), 8-10 oz. milk (2%)
Snack --- --- ---
If a diet recall is not appropriate for this patient, please explain why in the space provided:
A rough dietary recall was obtained from patient’s daughter d/t patient being sedated s/p total
gastrectomy.
FoodRecallAssessment
Part A
1. Analyze the recall using MyPlate Guidelines
According, to the patient’s daughter, this was not exactly a normal day of eating for this patient.
The types of foods are the same, but the amount eaten throughout the day is great. The patient had
been experiencing decreased appetite for a week or so, hence the reduced intake. In terms of
MyPlate guidelines, this patient was on target for the servings of grains and protein that he needed
to be eating (though the grains were all refined). The patient was <50% on target for his fruits,
vegetables, and milk/dairy foods. This patient has a history of hypertension, and according to his
daughter he does not follow a terribly low-sodium/cardiac diet. He does though, enjoy various
‘greens’, such as collard/mustard greens, as well as green beans, and broccoli, which would have
increased the nutritional content of his diet had he eaten some of these foods during these 24 hours.
This recall is high in refined grains, and contains several sources of saturated fat, sodium, and
processed foods. This recall was low in fresh fruits and vegetables, whole grains, legumes, fiber,
and adequate sources of nutrient dense foods.
Part B
1. Analyze the recall using a computer nutrient analysis program of your choice.
2. Attach the computer analysis output to this assignment.
3. Explain the adequacy of the intake below in terms of macro and micro nutrients.
The following is rough dietary recall of this patient’s daily intake. Portion sizes and quantities were
estimated based on daughter’s interview and perceived portion sizes consumed. MyPlate
SuperTracker gave this patient a 2,000 calorie daily intake, based on his weight, height and lack of
physical activity.
This patient’s rough daily intake was high in the non-desirable nutrients and low in the desirable

4. ones. He fell short of his calorie intake by 589 calories (due to his recent decreased appetite),
exceeded his carb intake by 31 grams and exceeded his saturated fat intake by just 1%. He was also
a high in sodium (2953 mg as compared to <2000 mg – due to hypertension). This patient was low
in his dietary fiber (14g as compared to 25g), his alpha-linolenic acids, calcium, potassium,
vitamins A, C, D, E, K, and folate, though his B6 and B12 levels were good. Overall, this diet was
high in macronutrients and sodium, and low in most vitamins and minerals.
Nutrition FocusedPhysicalAssessment
Physical Appearance Appeared well nourished, though overweight
Muscle and fat wasting N/A
Swallowing function Good
Appetite Poor – patient s/p total gastrectomy (NPO) and
sedated
*Appetite poor x 1week prior to admission due to
increased stomach/abdominal pain
Affect (e.g. lethargic, sleeping, coma,
energetic, in pain, etc.)
Sedated, agitated first few days. Patient calmed and
became more alert and oriented a few days after
surgery.
LABORATORY DATA:
Date: 11/4 Date: 11/5 Date: 11/7-8 Date: 11/10 Date: 11/11
Laboratory Test: Normal Values: Values: Values: Values: Values: Values:
Diet Order --- NPO NPO Clear Liquid Postgast Pureed Postgast Pureed
Height --- 66in 66in 66in 66in 66in
Weight --- 174# 174# 174# 174# 174#
Blood Pressure 120/80 --- --- --- --- ---
Albumin > 3.5 mg/dL 2.4 --- 2.4 --- ---
Sodium 135 –145 mEq/L 126 139 120 147 142
Potassium 3.7 – 5.2 mEq/L 3.0 3.8 4.0 3.2 3.5
Chloride 96 – 106 mEq/L 101 109 116 114 110
Carbon Dioxide 23 – 29 mEq/L 25 24 26 26 22
Glucose <140 mg/dL 192 124 130 149 131
BUN 7 – 20 mg/dL 14 21 33 44 36
Creatinine 0.7 – 1.3 mg/dL 1.75 2.27 3.38 2.71 2.42
GFR > 60 48 35 22 29 33
Magnesium 1.2 – 2.2 mg/dL --- 1.6 2.5 2.2 2.1
Phosphorous 2.4 – 4.1 mg/dL --- --- --- 3.7 ---
Hemoglobin/Hematocrit 12 – 16 g/dl / 36-
48%
10.6/33.8 9.9/31.2 10.2/33.2 10.0/33.2 10.3/33.2

5. DISCUSSION of Laboratory Data
Instructions:
Discuss the relation of laboratory values to disease state and nutritional status.
Consider the following:
 What significance do the abnormal laboratory results have for this patient
(example: type anemia? type hyperlipidemia)?
 If the case is being completed during a rotation where minimal laboratory data is available
(such as WIC), provide a discussion regarding what labs would be helpful in completing a
more complete assessment of the patient/client.
Electrolytes:
- During the first few days after this patient’s surgery, his electrolyte levels tending to be
towards the lower range, and they fluctuated until he became more stable by the final day.
Anesthesia can cause dehydration, and because of this, this patient was placed on different
IV fluids, which could have caused the fluctuating electrolyte levels until we were able to
stabilize him. This patient’s GFR was trending down during most of his stay, which could
have accounted for the varying electrolyte levels.
Blood Work:
- This patient continued to display a low hemoglobin/hematocrit, which could have arisen
from several factors. If the patients diet prior to admission was not nutritionally adequate,
he could have been missing out on sources of blood nutrients, such as iron. Low H/H can
also arise from cancer in the body, which is the likely case for this patients low H/H levels.
We also removed his entire stomach during his stay, which accounts from some blood and
tissue loss.
Other:
- This patient’s glucose levels were continually high during his recorded lab tests. High
glucose levels are not always a sign of poorly controlled blood sugars, but can be a sign of
stress within the body. Hormones, such as corticosteroids (including medications), are
released during times of illness, infection, or stress on the body, which can explain this
patient’s high levels during his stay.
- His GFR was also tended to be low, which is a measure of kidney failure and can represent
onset kidney failure in this patient, either occurring prior to her stay, or advanced in the
hospital - often, kidney function tends to decline the longer a patient stays in the hospital.
According to a study published in the Oxford Journals titled “Treatment-related acute renal
failure in the elderly: a hospital-based prospective study”, acute kidney injury is a common
occurrence in the elderly hospitalized population. The researchers found that, among the
various different causes of acute kidney injury, surgery (specifically abdominal surgery)
was a large contributor. This study mirrors the situation of this patient who underwent a
total gastrectomy and then began to show declining kidney function. One the last stay of
his stay, his kidney function finally began trending upwards.
http://ndt.oxfordjournals.org/content/15/2/212.full

6. MEDICATIONS:
Date: Medication&Amount: Purpose or Function: Significant Nutritional Implications:
11/4 –
11/5
Ciprofloxacin IV @ 200
ml Q12H
An antibiotic in a group of drugs called
fluoroquinolones. Ciprofloxacin fights
bacteria in the body.
Do not take ciprofloxacin alone with dairy
products such as milk or yogurt,or with
calcium-fortified juice. It could make the
medication less effective.
11/4 –
11/10
Heparin IV 0.5 ml Q12H An anticoagulant that prevents the
formation of blood clots. Used to treat or
prevent these clots in the veins, arteries,
or lung. Heparin is also used before
surgery to reduce the risk of blood clots.
Avoid alcohol, as heparin causes blood
thinning and alcohol only exacerbates this
effect.
11/6 –
11/10
Metoprolol @ 5 mg slow
IV push Q4H
A beta-blocker that affects the heart and
circulation Metoprolol is used to treat
angina and hypertension is also used to
treat or prevent heart attack.
Metoprolol should be taken with a meal or
just after a meal.
11/4 –
11/8
Protonix @ 40 mg IV push
daily
Proton pump inhibitor that decreases the
amount of acid produced in the stomach
– important if patient receiving little to
no oral nutrition to prevent ulcers.
Medication can cause diarrhea, but
antidiarrheal pulls should be avoided, unless
physician indicated.
11/4 –
11/10
NaCl 0.9% @ 125 ml/hr. Used to provide sodiumand water to the
body to aid in rehydration/hydration
maintenance
Medical histories of kidney problems, heart
problems (such as heart failure), body
water/salt imbalance should be considered
when administering NaCl.
11/4 Fentanyl @5 ml/hr. (w/
anesthesia - surgery)
Narcotic pain reliever, can be used as part
of anesthesia to help prevent pain after
surgery or other medical procedures
Side effects of fentanyl can include nausea
or vomiting, slowed heart rate and
hypertension,among others.Other drugs
such as vitamins and herbal supplements
11/7 –
11/8
Albumin human @ 100 ml
BID
Used to treat a variety of conditions,
including shockdue to blood loss in the
body,burns, low protein levels due to
surgery or liver failure, and as an
additional medicine in bypass surgery.
Severe allergic reactions (rash; hives;
itching; difficulty breathing; tightness in the
chest; swelling of the mouth, face, lips, or
tongue); change in heart rate or breathing;
chills; confusion; excess saliva; fainting;
fever; headache; nausea; vomiting;
weakness.
11/4 –
11/10
Amlodipine @ 10 mg
daily
A calcium channelblocker. Amlodipine
relaxes blood vessels and improves blood
flow. Amlodipine is used to treat
hypertension or angina
Amlodipine is only part of a complete
program of treatment that may also include
diet, exercise, weight control, and other
medications. Follow diet, medication, and
exercise routines very closely. Drinking
alcohol can further lower your blood
pressure and may increase certain side
effects of amlodipine.
11/10
–
11/12
Warfarin @ 5 mg
(evenings)
An anticoagulant (blood thinner). It
reduces the formation of blood clots.
Warfarin is used to prevent heart attacks,
strokes,and blood clots in veins and
arteries.
Foods that are high in vitamin K (liver, leafy
green vegetables,or vegetable oils) can
make warfarin less effective. If these foods
are part of the diet, eat a consistent amount
on a weekly basis.

7. DISCUSSION of Medications
Instructions:
Discuss drug-nutrient interactions and side effects the medicines may cause that have nutritional
significance.
Consider the following:
 Include whether the patient exhibits any of these side effects.
 Discuss relevant relations of medications to disease symptom complaints.
- Several of these medications cause side effects such as nausea, vomiting, diarrhea, rash,
facial/mouth swelling, etc. Fortunately, this patient did not experience any of these side
effects during his inpatient stay. We met with this patient almost every day after his surgery
to assess how his bowels were recovering and handling the onset of different degrees of diets.
He never had complaints of nausea or vomiting and experienced very little, mild diarrhea
while we were bringing him into more solid foods.
- In terms of nutritional/dietary implications, once specific medication that we educated this
patient on was the interaction between Coumadin (warfarin) and vitamin K. This patient
starting taking - Coumadin during his inpatient stay, and had thus no prior education. He had
a preference for dark, leafy greens (high in vitamin K) such as collard and mustard greens, so
he needed education on keeping a consistent intake of these foods while in Coumadin to
avoid issues with INR fluctuation and blood thinning/clotting inconsistencies.
- Ciprofloxacin has specific nutrient interactions with milk, yogurt and calcium fortified juice,
but these were non-issues since he was totally NPO while on his Cipro IV.
http://www.drugs.com
Nutrition Care Manual: Client Education – Warfarin and Vit K

8. NCP Step 2: Nutrition Diagnosis
PATHOPHYSIOLOGY
CURRENT MedicalConditions/Diagnoses
List ALL current medical conditions and describe the pathophysiology of each. Add
additional rows as needed. Be sure to reference your findings. Diagrams may also be helpful
in explaining the pathophysiology of some diseases/conditions.
Gastric Cancer
- Gastric cancer is described as cancer that occurs in the tissues of the stomach. According to the
National Cancer Institute, each year in the United States, about 13,000 men and 8,000 women are
diagnosed with stomach cancer. Most are over 70 years old. This patient presented with two of the
above risk factors for gastric cancer: being a male over 70 years old. This patient developed his
gastric cancer several years ago, and it had reached a recent degree of severity that called for a total
gastrectomy. Like other forms of cancer, gastric cancer develops in the cells of the stomach tissue.
Normally, cells grow and divide to form new, healthy cells. In cases of cancer, the cells develop
incorrectly and the mechanism for spotting these issues with the cell is missed. This allows the
damaged to cell to multiply and grow and take over the
healthy cells of the tissue. The buildup of these damaged
cells eventually forms a mass of tissue called a growth,
polyp, or tumor. Again, as with other cancers, gastric
tumors can be considered benign or malignant. In the case
of this patient, he was experiencing malignant cancer,
which means that the tumor was continuing to invade the
surrounding tissues and damaging the healthy tissue of his
stomach. As his cancer spread, he continued to lose normal
stomach function. Several weeks before his surgery, his
family noticed that his appetite was decreasing and he was
experiencing more stomach pain then usual. This patient
and his family has considered that a total gastrectomy may
occur, and these symptoms prompted his family to make
the outpatient surgical appointment.
http://www.cancer.gov/cancertopics/wyntk/stomach/WYNTK_stomach.pdf
S/P Total Gastrectomy | Esophageal Jejunostomy |
Enterenterostomy
- A total gastrectomy is exactly what it sounds: a complete
removal of the stomach. This also calls for an esophageal
jejunostomy, which is a connection of the lower end of the
esophagus with the jejunum of the small of intestine. The
procedure for this process calls for a connection of the
jejunum with the end of the esophagus, thus maintaining a
continued path from the start to end of the digestive system.
Eventually, the connection between the jejunum and
esophagus will grow a bit in size and begin to take over the
function of the stomach, to some degree. The pancreatic
juices will continue to flow into the small intestine to help
digest the food that is consumed. This will make it easier for the patient to eat a fairly

9. normal diet and hopefully avoid issues of Dumping
Syndrome.
- Apart from the total gastrectomy and the
esophagealjejunostomy, this patient also underwent
an enteroenterostomy. It is used to restore bowel
continuity after resection of a segment of the bowel
or after creation of a Roux-en-Y loop of jejunum.
When performed as a bypass procedure,
enteroenterostomy relieves bowel obstruction,
though this was not the specific case for this patient.
http://emedicine.medscape.com/article/1891769-technique
http://www.nostomachforcancer.org/gastric-cancer/life-
without-a-stomach/youre-having-what-about-total-
gastrectomy

10. PAST MedicalConditions/Diagnoses
Gastric Cancer
- See above definition
Hypertension
- Hypertension is defined as persistently high arterial blood pressure. The systolic blood
pressure has to be 120 mmHg or higher or he diastolic blood pressure has to be 80 mmHg or
higher (higher then 120/80) to be clinically defined as hypertension. Hypertension is divided
into two groups: primary – which often has no identified etiology and tends to develop
gradually over many years and, secondary – which is caused by an underlying disease, such
as kidney, adrenal, or thyroid problems, certain medications, alcohol abuse, etc. The
pathophysiology of hypertension includes several key points: increased systemic vascular
resistance, increased vascular stiffness, and increased vascular responsiveness to stimuli.
Basically, there is increased pressure on the arteries, causing increased smooth muscle
formation to make up for this pressure, ultimately leading to increased arterial resistance.
From a nutritional standpoint, the onset of hypertension can be preceded by a high sodium
diet. Sodium pulls water with it, thus increasing fluid volume in the blood and increased the
pressure on the vascular walls of the arteries. The heart also tends to work harder to pump
blood through the body. Following this type of
diet for a long time continues to put pressure on
these walls and raises blood pressure to a point
that one is finally diagnosed with hypertension.
This extra pressure and pumping of the heart can
damage the heart muscle and lead to other
cardiovascular complications.
- In the case of this patient, it was obtained from his
daughter that the foods he ate tended to be high in
salt and he did not have any previously followed
“low-sodium” diets. He did enjoy a variety of
healthy foods, but his age paired with his
preference for friend and some sodium heavy
foods contributed to his history of hypertension.
http://www.mayoclinic.org/diseases-conditions/high-
blood-pressure/basics/symptoms/con-20019580
Arthritis
- Arthritis is defined as inflammation/swelling of one or more of one’s joints. There are several
different types of arthritis, the most common of which being osteoarthritis and rheumatoid arthritis.
Osteoarthritis is a chronic condition in which cartilage between the joints breaks down. This causes
the bones to rub against each other, causing stiffness, pain and loss of joint movement. The cause is
not fully understood. Rheumatoid arthritis on the other hand, is an autoimmune disorder in which
the body causes the immune system to function abnormally and mistakenly attack healthy cells,
specifically the synovium - a thin membrane that lines the joints. This attack results in fluid build
up in the joints, causing pain and inflammation. Over time, this can wear away the cartilage and
bone, causing limited function and mobility. In most people, the inflammation usually becomes
systemic, affecting organs such as the skin, heart and lungs.
http://www.arthritis.org/

11. MedicalConditions/DiagnosesINTER-RELATIONSHIPS
Describe the inter relationship of the patient/clients disease states.
The use of a diagram is encouraged, but the diagram must be accompanied by a narrative
explanation. Be sure to reference your findings.
- The biggest inter-relationship that this patient displays is between his history of gastric cancer
and his surgery that was performed. As explained above, gastric cancer – if malignant and
spreading – can damage enough healthy tissue that it becomes necessary for part of all of the
stomach to be removed. Apart from pain and discomfort relief, this procedure is also done to
protect the rest of body from the spread of the cancer, as well as protect the integrity of the
gastrointestinal tract. According to No Stomach for Cancer, Inc. the recommended procedure
to prevent the development or spread of gastric cancer is prophylactic (preventive) total
gastrectomy. People with other forms of stomach cancer may also undergo total gastrectomy
as part of their treatment plan. Total gastrectomy is also performed to treat some non-cancer
medical conditions. The reconstruction is referred to as Roux-en-y.
- The above diagrams show the before and after picture of a total gastrectomy. The part of the
small bowel that is initially cut at the end of the duodenum is what is extended straight up to
meet the esophagus (esophagealjejunostomy). That cut end of the duodenum is then
reconnected to the small bowel. The procedure takes 4-5 hours followed by a hospital stay of
7-12 days. In the case of this patient, he was admitted for roughly 8 days. According to No
Stomach for Cancer, Inc. no food or drink is permitted for the first 5 days, not even ice chips.
This patient healed quite well from his surgery and we were able to administer a clear liquid
diet by day 4, which we tolerated quite well and had no instances of leakage, diarrhea,
abdominal discomfort or other GI issues.
http://www.nostomachforcancer.org/gastric-cancer/life-without-a-stomach/youre-having-what-about-
total-gastrectomy

12. AssessmentofNutrition Needs basedof off 79kg (pt’s actualweight)
Calories: 2,370 kcals
Show your work:
30 kcal/kg
30 kcal/kg x 79 kg = 2,370 kcals
Rationale for calorie level:
It was enough calories to ensure that the patient did not experience any weight loss and had enough
kcals to promote healing after his surgery.
Protein: 103 g
Show your work:
1.3 g/kg
1.3 g/kg x 79 kg = 103 g pro
Rationale for calorie level:
Increased protein needs are necessary for hospitalized individuals. Advocate Trinity’s standard is 1.0
g/kg protein for hospitalized adults. In addition, this patient underwent surgery and as such, needs
increased protein needs to promote healing and avoid a catabolic state. 1.3 g/kg is an appropriate
protein amount to meet his increased needs, avoid a catabolic state, and also avoid an excess amount
of protein.
Other pertinent micronutrient levels:
Show your work:
B12 shots – likely monthly (prescribed by physician)
* Amounts vary between 500mg and 1,250mg depending on the amount needed and the presence of
any long-term B12 deficiency
Rationale for pertinent level:
Since his entire stomach was removed, this patient no longer has intrinsic factor to transport any
dietary B12 into his small bowel for absorption. In order to prevent a B12 deficiency that can lead to
unfavorable neurological deficits, we advised this patient and his family that B12 shots will be
necessary. They were to speak with their physician regarding the exact amount and occurrence of
these shots.
http://www.mayoclinic.org/drugs-supplements/vitamin-b12/dosing/hrb-20060243
Fluid: 2,370ml
Show your work:
30 mL/kg
30 mL/kg x 79 kg = 2,370 ml
Rationale for fluid level:
To match his increased kcal needs necessary to promote healing, increased fluid needs are also
required. When a person undergoes anesthesia, there body will undergo dehydration and needs
increased fluid.

13. Which of the following domainsis the patient/client presenting with:
DOMAIN Check () if patient
presents with this
characteristic
If checked, explain evidence to support this
decision
INTAKE
Nutrient Intake

1) Due to the total gastrectomy, this patient’s
nutrient intake was restricted for 2 days, and
then his diet was carefully advanced as
tolerated.
2) As stated above, this patient has no intrinsic
factor to absorb B12, so B12 shots will be
necessary to fix this nutrient intake issue.
CLINICAL
Functional

This patient displays altered GI function due to
a total gastrectomy, thus affecting his nutrient
intake and needs to be corrected with monthly
B12 shots. This patient also needed to
gradually advance his diet as tolerated to
compensate for his altered GI function.
BEHAVIORAL-ENVIRONMENTAL
Knowledge and Beliefs

This patient had a knowledge deficit regarding
his diet post-total gastrectomy, as well as the
food/drug interaction between Coumadin and
vitamin K, and thus required education on
these topics.
What is the Nutrition Diagnosis for this client/patient?
Diagnosis or
Problem
Etiology Signs and/or Symptoms
Altered GI function
Food and Nutrition
Related Knowledge
Deficit
Related to
Related to
GI Surgery
Lack of
Exposure to
Prior
Information
Related to
Related to
Need for NPO status
GI Surgery and New
Medication

14. NCP Step 3: Nutrition Intervention:
Nutrition Prescription (Diet Order)
Indicate the diet changes and progression since patient’s admission to present
Date Diet Prescription/Order
11/4 NPO
11/7 NPO
11/8 Clear Liquid
11/10 Postgastrectomy Pureed
11/11 Postgastrectomy Mechanical Soft
DiscussionofDiet Order(s)
Consider:
 Rationale & indications for current diet order
 Do you agree with the order? Discuss why or why not.
 Would any other dietary modifications be realistic and appropriate? Discuss why or why
not.
This is a proper diet order and advancement for a patient with this type of gastric surgery. Initially
the patient was to remain NPO for the first few days after surgery to give the bowels time to rest and
heal. He was then advanced to a clear liquid diet for one day, which he tolerated well. This patient
was then advanced to a postgastrectomy pureed and then mechanical soft diet, which again he
tolerated well. One reason for this type of diet advancement and prescription order is to avoid
dumping syndrome as well as delayed gastric emptying. Dumping syndrome occurs when the
undigested contents of the stomach (or small intestine if the stomach is removed) move too rapidly
into the small bowel. Common symptoms include abdominal cramps, nausea and diarrhea. By
following a postgastrectomy diet (which consists of small portions, beverages between meals, and
no concentrated sweets), dumping syndrome can be avoided. In the case of delayed gastric
emptying, the reported incidence of delayed gastric emptying (DGE) after gastric surgery is 5% to
25% (according to the American Journal of Surgery). A research article published by the American
Journal of Surgery studied the occurrence of delayed gastric emptying (DGE). They discovered that
DGE continues to affect a considerable number of our patients (24%) after gastric surgery and is
particularly common in patients with diabetes, malnutrition, and gastric or pancreatic cancer.
However, gastric motility does return in 3 to 6 weeks in most patients and the need for re-operation
for gastric stasis is rare. In the case of this patient, his recovery went smoothly and he is expected to
resume an almost 100% normal diet within 6 weeks of his surgery.
http://www.sciencedirect.com/science/article/pii/S0002961096000487
http://www.mayoclinic.org/diseases-conditions/dumping-syndrome/basics/definition/con-
20028034

15. Nutrition Intervention Plan
Problem Etiology of
the
Problem
Sign/Symptoms Intervention Goals for this Intervention
Altered GI
function
GI Surgery Need for NPO
status
Food and/or Nutrient Delivery:
- For this patient, we spoke with his daughter
about diet advancement as appropriate once
okay with the surgery department. We
expected a transition to oral diet in the first
few days following his surgery pending the
return of his bowel function. Plan was to
monitor indications for diet advancement vs.
prolonged NPO status and need for TPN
support.
The first and most important goal for this
intervention is appropriate diet progression for this
patient. The patient was agitated and confused during
the first 2 days after his surgery, so we worked with
his daughter to ensure that his diet was progressing as
expected. He was NPO for about 3 days after the
surgery, and then was able to be advanced to a clear
liquid diet, then a postgastrectomy pureed and finally
a postgastrectomy mechanical soft. Overall, this
patient tolerated his diet progressions well and had
wonderful family support to ensure that he was
following the proper postgastrectomy diet, as is
explained below.
Food and
Nutrition
Related
Knowledge
Deficit
Lack of
Exposure to
Prior
Information
GI Surgery and
New Medication
Nutrition Education:
- Along with ensuring proper dietary
advancement, we needed to make certain that
this patient was following a proper
postgastrectomy diet: no concentrated sweets,
eating small meals, chewing thoroughly, and
having beverages in between meals, all to
avoid dumping syndrome.
- This patient was also receiving Coumadin,
which required Coumadin/Vit K drug-nutrient
interaction education.
- Need for B12 shots post D/C
We worked with his daughter, and the patient himself
(once he became more alert by day 3) to explain the
proper way to resume his ‘normal’ diet. Both the
patient and daughter were extremely compliant with
the new dietary orders and the patient tolerated all
dietary advancements extremely well. The kitchen
was responsible for avoiding the concentrated sweets
and providing smaller portion sizes, but the patient
and family were responsible for ensuring that all food
was chewed thoroughly and that beverages were
consumed in between meals. This patient also was
receptive to the Coumadin/Vit K interaction
education and demonstrated an acceptable level of
knowledge and understanding regarding this new
medication.

16. Nutrition Intervention Plan
Nutrition Prescription
Current order: Postgastrectomy Mechanical Soft (diet prescription at time of discharge)
Your Nutrition Prescription
Recommendation:
Continue same type of diet at home and advancement of diet as tolerated
Which goal is the priority at
this time?
Proper diet advancement.
If instruction was given, who
did you instruct?
Patient and daughter
What instructional materials
did you use? Where they
effective? Why or why not?
Nutrition Care Manual – Coumadin/Vitamin K drug-nutrient interaction. The materials and
explanation were effective, and copies were made for the patient and daughter.
If patient has been education,
what is their
motivation/compliance level at
this time?
Both patient and daughter were quite motivated and entirely compliant with the all the nutritional
education given. His daughter had come prepared with research regarding his surgery and the
nutritional implications for post-surgery. Overall, his family (including other sons and daughters)
were incredibly involved in his recovery and receptive to all education and information given.
Does the patient have any
barriers to compliance to the
interventions?
None – see description of involved family above.

17. NCP Step 4: Monitoring and Evaluation
Health Care Outcomes
Basedon your Nutrition Intervention indicate below what outcome measurements you will use to monitor
progress and success of the interventions.
Complete for all interventions listed in Part 3.
Intervention
Health & Disease
Outcomes
CostOutcomes Patient Outcomes
Proper diet
advancement
post GI surgery
- Proper healing and
bowel rest
- Avoidance of surgical
complications (ie.
sepsis, infection,
internal bleeding)
- Normal WBC levels,
which indicate no
infection occuring
- Cost of patient stay: the
quicker the patient can
heal and be discharged,
the less expenses that are
endured on his recovery
(including lab test, meals,
IV fluids, nursing
staff/hours, etc.)
- Toleration of diet advancement,
including avoidance of nausea,
vomiting, diarrhea, cramps, pain, etc.
- Proper healing of bowels post surgery
- Improvement in patient alertness and
orientation during days following
surgery
Diet and
Drug/Nutrient
interaction
education
- Ensure proper dietary
behaviors appropriate
for a postgastrectomy
diet to ensure avoidance
of dumping syndrome
and delayed gastric
emptying
- Cost of meals to be
delivered to patients, as
well and any costs
endured through
complications of GI
distress (dumping
syndrome, DGE)
- Demonstrating an acceptable level of
understanding regarding a proper post-
gastrectomy diet advancement as well
as the drug/nutrient interaction
regarding his Coumadin medication
and vitamin K foods.
Monitoring and Evaluation
Question to Consider Answer/Reflection
What indices are you using to determine success
of your intervention?
Proper healing post-surgery, toleration of diet advancement
as well as understanding nutrition education
Did the intervention work? Explain Yes – the patient recovered well and showed proper
understanding of nutrition education given to both patient
and family.
If the intervention is not working, indicate what
follow up action you took.
N/A
What are the causes of initial interventions that did
not work?
All interventions worked well for patient.
How will you monitor success of your follow up
interventions?
Continue to monitor diet advancement and toleration,
provide addition educations as necessary, and ensure that
patient was not readmitted for issues relating to GI distress.
DOCUMENTATION
Attach all initial and follow up notes for this patient/client to this report. Be sure to delete any data
that may identify the patient such as name or room number.

18. References
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2. Bar-Natan, Marcos MD, et. all. Delayed gastric emptying after gastric surgery. Am J of
Surgery. 1996. doi:10.1016/S0002-9610(96)00048-7
3. Coppinger T, Jeanes YM, Hardwick J, Reeves S. Body mass, frequency of eating and
breakfast consumption in 9-13-year-olds. J Hum Nutr Diet. 2012; 25(1): 43-49.
doi:10.1111/j.1365-277X.2011.01184.x
4. Drugs and Supplementation: Vitamin B12. Mayo Clinic Website.
http://www.mayoclinic.org/drugs-supplements/vitamin-b12/dosing/hrb-20060243 Accessed
November 14, 2014.
5. Dumping Syndrome. Mayo Clinic Website. http://www.mayoclinic.org/diseases-
conditions/dumping-syndrome/basics/definition/con-20028034 Accessed November 14, 2014
6. Enteroenterostomy Technique. Medscape Website.
http://emedicine.medscape.com/article/1891769-technique Updated September 2013. Accessed
November 14.
7. Kohli, Harbor S. Treatment-related acute renal failure in the elderly: a hospital-based
prospective study. NDT Oxford Journals. (2000)15 (2): 212-217.doi: 10.1093/ndt/15.2.212
8. High Blood Pressure (Hypertension). Mayo Clinic Website.
http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/basics/symptoms/con-
20019580 Accessed October 17th
9. Stomach (Gastric) Cancer. National Cancer Institute at the National Institutes of Health
Website. http://www.cancer.gov/cancertopics/wyntk/stomach/WYNTK_stomach.pdf Accessed
November 14.
10. Types of Arthritis. Arthritis Foundation Website http://www.arthritis.org/ Accessed
November 14, 2014