Baylee Leonhardt

Case Study Assignment

8. 44 YOBM admitted for laproscopic cholecystectomy due to gall stones. 16 weeks post rouxen-y gastric bypass surgery. PMH: obesity, hypercholesterolemia, diabetes. Ht: 62, Wt: 308
lbs. Wt before surgery: 347 lbs. Diet order: regular. Intake: 90%. On post-op day 1,
discussion with patient about nutritional concerns leads him to state that the weight loss
physician is less than happy with his progress. Patient wants to know what he should be eating.
Does not suffer from dumping syndrome. Admits he hasnt been good about taking his vitamin
supplement or exercising and is feeling like a failure. Says wife hasnt changed cooking habits
since his surgery. Labs: Hgb: 12.8 g/dL, Hct: 38%, Alb: 3.6 g/dL, Pre-Alb: 20 g/dL. Meds:
ibuprofen, Lipitor.

1. Explain the conditions the patient has.

The patient was admitted for a laparoscopic cholecystectomy surgery due to gall stones.
The most common cases of gallstones are caused by an over-abundance of cholesterol
within the body (1). These stones are commonly found due to the excessive amount of
cholesterol trying to be absorbed, which overworks the gall bladder (1). In result, the gall
bladder fails to hold the amount of bile needed for bodily functions due to the presence
of excess cholesterol and fat (1). In order to treat the gall stones, a laparoscopic
cholecystectomy can take place which is a non-aggressive procedure done to
completely remove the gall bladder (2). This type of surgery is extremely beneficial
among gallstone patients due to the short recovery time post-surgery which helps with

limiting the occurrence of pain and medical costs (2). This operation is also proven to
have a low incidence of problems and/or death (2).

The patient will be undergoing this procedure 16 weeks after experiencing a Roux-En-Y
gastric bypass surgery. Roux-En-Y gastric bypass surgery is commonly done in
clinically obese patients (3). This procedure is summarized by forming a smaller
stomach and attaching it to the small intestine (3). This eliminates the rest of the
stomach and a section of the duodenum, making the absorption of food decrease (3).
According to research, this type of bariatric procedure is preferred and can result in a
substantial loss of weight for longer periods of time (3). Although this surgery is known
as a great tool for weight loss in obese patients, there are some complications that a
patient could endure post-operation (3). One of these complications includes the
formation of gallstones which coincidently happened with this patient (4).
The patient has a past medical history of obesity, high cholesterol levels, and diabetes.
With these heath conditions, the patient is at high risk for problems post-operation. He is
now seeking dietary advice.

2. Discuss the most common nutritional consequences of these conditions.

There are many short-term and long-term nutritional consequences of gastric bypass
surgery along with gall bladder removal. Because complications such as leaks, bowel
obstructions, excess bleeding, and wounds are common after these types of procedures,
it is important for the patient to be aware of their nutritional needs (3). Unfortunately,
vomiting and dumping syndrome are common issues in these patients, making it hard for
their bodies to absorb the adequate amounts of nutrients within the diet (4). Common

nutritional deficiencies include vitamin B12 and iron (4). It is important for these patients
to be consuming sufficient amounts of protein in their diet and taking a multivitamin daily
(4). Some multivitamins may not contain sufficient amounts of iron and B12, so it is
important for these nutrients to be included within the diet as well (4). Protein is an
essential macronutrient needed for these patients so it is important to keep checking
their albumin levels, making sure they do not become protein deficient (4). Other
deficiencies commonly seen include inadequate amounts of fat-soluble vitamins,
especially A, D, and K, which can result in calcium deficiency, excess bone loss, and
hyperparathyroidism (4).

Although what is stated above are the most common deficiencies seen in bariatric
patients, other micronutrient deficiencies have been seen such as thiamine, magnesium,
zinc, and selenium deficiency (5). This reiterates the importance of multivitamin
supplements. Taking a multivitamin supplement will increase a patients chance in
absorbing most of the nutrients needed if they cannot be absorbed completely through
food.

3. What information is needed from the patient? List questions you would ask the patient
and explain how those answers would impact your course of action for example, if the
chart noted weight loss and you learned from the patient interview that the weight loss
was intentional would that change your plan of care compared to if the weight loss was
unintentional? I realize that the information you are given is incomplete. This is where
the patient interview is helpful, so you can make up answers to these questions to help
with your assessment.

Information needed from the patient: A 3-day food record prior to bariatric surgery & after
bariatric surgery
Questions asked to the patient:
1.) Employment?
-Factory worker
2.) Any kids?
-No kids, just married
3.) Family history of disease?
-Type II diabetes, obesity, cardiovascular disease
4.) When were you diagnosed with high cholesterol?
-About 4 years ago, 40 years old.
5.) When were you diagnosed with diabetes? Type I, Type II?
-Type II diabetes, and about 8 years ago, 36 years old.
6.) Involved in any leisure activities?
-Too busy with work, 40 hrs a week of work, works 3rd shift, sleeps all day
7.) What was your normal eating style & meals like before bariatric surgery?
-Very abnormal eating pattern, eats out a lot, too busy to cook meals, wife cooks
meals if we eat at home.
8.) How were your normal eating style & meals like after bariatric surgery?
-Meals havent really changed, still eat out a lot, wife hasnt changed cooking
9.) What was your physical activity before bariatric surgery?
-Stopped exercising way back in his 20s. Lost track of his weight.
10.)

What was your physical activity after bariatric surgery?

-Tries to go on more walks with the dog post-surgery, a little bit more effort in being
active.

11.)

Alcohol consumption?

-Occasionally, 2-3 drinks a week, mostly just on special occasions.

12.)

Skip meals often?

-Usually skips breakfast, after getting off work, he just goes to bed and eats lunch
and dinner.
13.)

Binge on meals often?

-Probably more than he should, never knows when he is going to eat next
14.)

Do you check blood sugar often?

-Probably a couple times a week, usually whenever he thinks about it.

15.)

What types of foods do you eat usually?

-Fried chicken, macaroni and cheese, comfort foods when wife cooks
-When going out to eat: Mexican restaurants, McDonalds, Wendys.
16.) Has your weight loss been intentional?
-Yes, to some extent, there has been more effort in physical activity, but still
doesnt feel like he is doing enough. Feels like he needs to improve diet and
eating habits.
17.) Have you had any known issues after surgery? GI distress?
-No issues that he can see as of now.

4. Determine BMI and estimate energy and protein needs based on the current condition.
Show your work and explain why you used the formula and activity factor you did.

BMI: 39.6 (Obese)

62 = 74 inches x 2.54 = 187.96 cm = 1.8796 m = 3.53 m squared
308 lbs / 2.2 = 140 kg
140 kg / 3.53 m squared = 39.6

Estimated Energy Needs: 4,060 kcals/day

Mifflin St. Jeor: (10 x 140 kg) + (6.25 x 187.96 cm) (5 x 44) + 5 = 2349.75 x 1.44 x 1.2
= 4060 +/- 10%
IF= 1.44 (elective surgery)
AF=1.2 (confined to bed post-op day 1)

IBW: 190 lbs

6 x 14 inches = 84 + 106 = 190 lbs (86.3 kg)

Protein Needs based on current condition: 130 g/kg/day

1.5 g/kg moderate stress
IBW x protein needs = 190/2.2 = 86.3 kg x 1.5 = 130 g/kg/day

5. Discuss the lab values that are outside normal limits why are they outside of normal?

The lab values that are outside normal limits would be the Hgb and the Hct. Normal
levels of Hgb for males should be within the range of 13.5-17.5 g/dL. With the patient at
a level of 12.8 g/dL, his hemoglobin is low which may lead to possible iron deficiency.
Normal levels of Hct for males should be within 41-53%. The patient showed a
hematocrit percentage level of 38%, which means that he has a low red blood cell count.
Low levels of this usually show iron deficiency and inadequate hydration status, meaning
this patient could be struggling with dehydration as well.

The albumin and prealbumin levels showed up within normal range, but were a little on
the low side of what is defined as normal. The normal range of albumin is in between
3.5-5.0 mg/dL and the normal range of prealbumin is in between 19-43 mg/dL. The
patient had an albumin level of 3.6 mg/dL and a prealbumin level of 20 mg/dL, which
could signify that the patient may be struggling with protein intake and could potentially
struggle with protein deficiency in the near future.

These labs do not surprise me at all. As stated above, patients who have undergone
bariatric surgery are at higher risk of developing iron and protein deficiency. These
levels are most likely outside of normal limits due to the malabsorption that could be
happening within the body.

6. Are there any labs you would order, if you could?

I would order a ferritin lab because it is the chief storage form of iron and would give a
better representation of the patients iron status, along with comparing it to the Hgb and

Hct labs. I would also order an LDL, HDL, and total cholesterol lab to get a better idea of
the patients cholesterol and fat levels within the blood. Since the patient has a past
medical history of diabetes, I feel that a hemoglobin A1C would be appropriate, to get a
better idea of his blood sugar status long-term. Although some tests may show higher
blood sugar if the patient has undergone surgery, I feel that it would still be useful to the
patient. Blood pressure would also be important to know due to the patients high BMI
and weight status, making sure that he is at a normal level. I would also order a total
calcium lab to ensure that the patient isnt deficient and isnt at increased risk of bone
loss and hyperparathyroidism.

7. What is your diet order prescription do you agree with what has been ordered?
Describe any modifications to be made these may include increasing or decreasing
macronutrients, adding or restricting certain foods or classes of foods, modifying
textures, etc.
I feel that the diet order is okay post operation day 1. Eventually, I feel that his diet
should include more protein and fluid to ensure adequate protein status and hydration.
The patient should also be taking a multivitamin and supplementing with enough iron
and B12 if there is not enough absorbed through food choices.

8. Explain the social factors that are positive and negative for your patient.

Negative social factors for the patient would include his wifes cooking habits. He claims
that she has not changed her cooking habits since his surgery which puts him at a
downfall when it comes to eating and incorporating a healthier diet into his lifestyle. Not
only do his lifestyle choices change but so should his spouses.

Even though the patients spouse is a big reason why he isnt eating healthier postsurgery due to her unchanged cooking style, she could get more education and practice
on cooking healthier meals for her husband which could turn into a positive social factor
for the patient.

9. List the medications taken, reason for use, impact on lab values, and any FDI or NDI.

Medications taken: Ibuprofen and Lipitor

The reason for Lipitor is to lower cholesterol within the patient. The impact this will have
on lab values would be to hopefully lower cholesterol within the bloodstream. Common
FDI/NDIs with taking Lipitor or any cholesterol-lowering medication are
grapefruits/grapefruit juice, garlic, blood thinners (Vitamin E), EPA, DHA, and flaxseed
oils.

The reason for Ibuprofen is to reduce incidence of inflammation, fever, and pain. The
impact this will have on lab values would be to keep them stabilized so that they do not
fall or rise to risky levels for the patient. Common FDI/NDIs with taking Ibuprofen are
anti-coagulants, vitamin C/ascorbic acid, DHA, EPA, ginger, caffeine, and fish oils.

10. List the potential nutrition problems using the appropriate diagnostic terms, e.g.,
inadequate fluid intake).

-Inadequate energy intake due to an 11% weight loss in four months

-Inadequate iron intake due to the lack of iron consumed in the diet
-Excessive fat intake due to the formation of gallstones

11. What is YOUR nutritional diagnosis? (1-3 PES statements)

Diagnosis 1:
-Inadequate iron intake, related to undesirable food choices, as evidenced by a low Hgb
level of 12.8 g/dL, a low Hct level of 38%, and failure to take multivitamin post-surgery.

Diagnosis 2:
-Excessive fat intake, related to undesirable food choices, as evidenced by BMI of 39.6,
hypercholesterolemia, and gallstones.

12. Establish a goal and intervention for each nutritional diagnosis noted in #11.

Diagnosis 1

Goal: Increase iron intake by incorporating iron-rich foods into the diet at least once a
day.

Intervention: Take multivitamin daily and incorporate iron-rich foods into the diet such as
spinach, lentils, and chickpeas.

Diagnosis 2

Goal: Decrease cholesterol/fat intake by incorporating lean meats into the diet such as
chicken and fish Stay away from red meats at every meal.

Intervention: Make every protein source come from chicken, fish, or legumes,
incorporate fruits and veggies into the diet, make overall meals lower in fat and higher in
other nutrients.

13. Complete ADIME note.

Nutrition Assessment
Client History:
-44 yo male
-African American
-Married, no kids
-Factory worker, third shift
-Past medical history of Type II diabetes, obesity, high cholesterol
-Family history of Type II diabetes, obesity, and cardiovascular disease

Food & Nutrition History:

-Skips breakfast often, lack of consistency at meal times
-Binge eats at meals

-Eats out a lot

-If not eating out, his wife does the cooking
-Drinks alcohol occasionally, 2-3 drinks week
-Eats a lot of comfort foods which are high in fat
-Claims to have no physical activity before and after surgeries

Anthropometrics:
-Height: 6 feet, 2 inches (74 inches)
-Weight: 308 lbs (140 kg)
-UBW (weight before bariatric surgery): 347 lbs
-IBW: 190 lbs (86.3 kg)
-%IBW: 162% (308/190 x 100 = 162%)
-BMI: 39.6 (Obese)
-% Wt loss: 11% wt loss in 4 months (347-308/347 x 100 = 11%) - Significant

Biochemical/Tests/Procedures:
Hgb: 12.8 g/dL
Hct: 38%
Alb: 3.6 g/dL
Pre-Alb: 20 g/dL

Nutrition Focused Physical Findings:

-Seems slightly tired, low energy
-No issues with GI distress, no dumping syndrome
-Good appetite, seeing some malabsorption issues with significant weight loss after only 4
months

Comparative Standards:
-Kcal Needs: 4,060 kcals/day
-Protein Needs: 130 g/kg/day

Nutrition Diagnosis
Diagnosis 1: (PES statement)
-Inadequate iron intake, related to undesirable food choices, as evidenced by a low Hgb level of
12.8 g/dL, a low Hct level of 38%, and failure to take multivitamin post-surgery.
Diagnosis 2: (PES statement)
-Excessive fat intake, related to undesirable food choices, as evidenced by BMI of 39.6,
hypercholesterolemia, and gallstones.

Nutrition Interventions
Nutrition Rx: General, healthful diet of 4,060 kcals per day.
Nutrition Ed:
-Purpose: To get on a good, balanced eating schedule by also increasing protein, hydration,
and iron intake while decreasing fat intake.
-Relationship to disease:
-Increased fat intake could cause cardiovascular disease
-Increased fat intake can also decrease chances of losing weight post-bariatric surgery

-Modifications:
-Eating out
-Dressing on the side
-Portion control (put half in a box to take home when first served meal)
-Limit number of times per week
-Special order foods to save on excess calories and fat
-Review the menu, scan for healthier options
-Skipping meals
-Pack healthy snacks at home to bring to work
-Pre plan meals
-Carry snacks in car or at work at all times
-Stray away from convenience foods
-Substitute lean meats for protein
-Little to no red meat in the diet
-Incorporate beans and legumes as protein sources

-Nutrition Counseling:

-Theories used:
Social Learning Theory: I showed the Pt the handout of the food pyramid and how to
incorporate different types of food into the diet. Since this diet is based on low fat foods, the
handout does a good job of explaining how much of each food group they should focus on and
gives examples and portions as well. I explained how they could incorporate these foods into
cooking at home and how his wife could play a role as well.

-Strategies used:
-Social support
-Goal setting
-Motivational Interviewing
-Keeping a food record
-Problem Solving (Pros and Cons)

-Applications used: A handout of a food pyramid specialized in educating patients on a low-fat

diet, similar to the DASH diet, which will be beneficial to them after gallbladder removal.

-Referral of Care:
-Doctor for further testing & blood work

Goals:
1 .Limit going out to eat Only twice per week, if at all.
2. Decrease cholesterol/fat intake by incorporating lean meats into the diet such as chicken and
fish Stay away from red meats at every meal.
3. Packing and pre planning meals to bring to work every day in order to decrease the
likelihood of skipping meals and causing disordered eating patterns.
4. Increase iron intake by incorporating iron-rich foods into the diet at least once a day, along
with taking a multivitamin daily.

Monitoring and Evaluation:

Monitoring & Evaluating:

-Monitor iron intake
-Take multivitamin daily
-Incorporate iron-rich foods into the diet such as spinach and lentils

-Monitor fat/cholesterol intake; goal is to cut down on red meats

-Make every protein source come from chicken, fish, or legumes.
-Incorporate fruits and veggies into the diet
-Pay attention to portion size, make sure meals are lower in fat, higher in other nutrients

14. Find or develop one educational tool for your counseling session.

http://www.24newsupdate.com/wp-content/uploads/2012/01/DASH-diet.jpeg
My educational tool for my counseling session is a food pyramid handout educating the patient
on what their diet should be like after experiencing gallbladder removal. They must stick to a
low fat diet, similar to the DASH diet, and this handout gives a great visual as to what they can
eat and how much they can eat.

References:
1.) Juvonen, T. (1994). Pathogenesis of gallstones. Scandinavian journal of
gastroenterology, 29(7), 577-582.
2.) Graves Jr, H. A., Ballinger, J. F., & Anderson, W. J. (1991). Appraisal of laparoscopic
cholecystectomy. Annals of surgery, 213(6), 655.
3.) Schauer, P. R., Ikramuddin, S., Gourash, W., Ramanathan, R., & Luketich, J. (2000).
Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Annals of
surgery, 232(4), 515.
4.) Fujioka, K. (2005). Follow-up of nutritional and metabolic problems after bariatric
surgery. Diabetes Care, 28(2), 481-484.
5.) Bloomberg, R. D., Fleishman, A., Nalle, J. E., Herron, D. M., & Kini, S. (2005). Nutritional
deficiencies following bariatric surgery: what have we learned?. Obesity surgery, 15(2),
145-154.