SOAP/ADIME Hybrid Form

Interval History: Pt is 47 YOF that has been admitted and scheduled for Roux En Y Gastric Bypass
surgery. Past medical history includes DM2, HTN, OSA, hyperlidemia, and chronic joint pain.

Anthropometrics:
Ht: 65 IBW: 125#
% IBW: 240
Ht (cm): 165.1 IBW (kg): 56.8
Admit Wt: 300# UBW: 310#
% UBW: 96.8
Admit Wt (kg): 136.4 UBW (kg): 141
BMI: 49.9
Current Wt: 300#
AIBW (for obesity): 169# BMI Class: Class 3 Obesity/
Current Wt (kg): 136.4
Morbid Obesity
Est. Dry Wt: Wt Hx: Pt states has be obese since she was teenager.
Est Dry Wt (kg): Persistent trouble losing weight.

Labs: Cholesterol 240, LDL 160, HDL 35, Trig 220, Glucose 180, A1c 7.4, Na 142, K
3.2

Current Meds: Metformin 500mg bid, Lisinopril 20mg, Lasix 40mg, Ibuprofen 600mg Q 6 hrs (prn
for pain).

Diet: Current diet order in preparation for surgery, NPO and on IVFS of NS @ 100Ml/hr. NPO for 1-2
days after surgery then advance to CL diet for 2-4 days. FL diet for 2-4 weeks. Diet order PTA, low
fat and low calories with soft/pureed foods. Pt is not taking any current supplements.

Nutrition Needs/Intake:
Wt: 136.4 kg Est. Needs

Calories 1,637-1,773 kcal/d

(12- 13kcal/kg)

81.8-109.1 g/d
Protein
(0.6-0.8g/kg/d)

Fluid 2,455-2,728mL/d
(18-20mL/kg/d)

Assessment: Pt presents with Class 3 Morbid Obesity (BMI 49.9) and associated diseases including
DM2, HTN, OSA and hyperlipidemia, awaiting Roux En Y Gastric Bypass Surgery.

Anthros: Pt has a BMI of 49.9 and is classified as morbidly obese. The Pt is currently 300#, 96.8% of
UBW. Pt has had trouble with weight loss since she was a teenager. Pt has a IBW% of 240% and an
AIBW of 169#.
Intake: Pts intake prior to admission for surgery was very high, consuming 3,893 kcal on an average
day. This meets 219.6% of pts estimated energy needs of 1,773 kcal/day. Pts usual diet includes
heavy snacking throughout the day and large portion sizes for each meal.

Labs: Pts labs indicate high levels of cholesterol, LDL, Triglycerides associated with hyperlipidemia
and uncontrolled DM2. Increased levels of Glucose and Glycated hemoglobin associated with poorly
controlled DM2. High levels of sodium likely related to dehydration. Low level of HDL related to
uncontrolled DM and tissue damage. Level of K likely low due to use of Lasix (diuretic). Labs show
and confirm presence of hyperlipidemia and uncontrolled DM2.

Medication: Pt is currently taking Metformin 500mg bid for as treatment of DM2, Lisinopril is a ACE
inhibitor that is used for treatment of HTN, Lasix is given at 40mg as a diuretic to treat fluid
retention and swelling, Ibuprofen is an NSAID used for pain.

Nutrition Diagnosis:
o Morbid obesity r/t poor PO intake and sedentary lifestyle AEB UBW 310#, BMI of 49.9,
%IBW 219.6% and physical exam notable for standing with aid of cane.
o Food and nutrition related knowledge deficit r/t less than ideal PO intake consisting of fast
food/takeout 4-5 times/week and excessive snacking of peanuts/peanut butter AEB
patients usual intake record and Pt interview noting Pts lack of education of health food
choices.
o Altered nutrition-related potassium laboratory value r/t use of Lasix diuretic AEB low lab
value of K+: 3.2.
Goals:
o Tolerance of CL diet with N/V/D
o Prevent dehydration
o Begin supplementation of RYGB vit/min
o Advance to FL diet as appropriate
o Initial RYGB diet education
o Monitor glucose trend

Interventions/Recommendations:
1. When medically appropriate, being CL diet
Low cal, no juice, low sugar, no carbonation, caffeine free
2. Once on CL diet, begin supplementation with the following: Chewable MVI and TE 2 tab/2
(200% DRI), 500mg Ca+ 3x/d (tums), 1,000 IU Vit. D3 3x/d (with Ca+), 5 mg Fe 2x/d (give sep
from Ca+), 400 mcg sublingual B12/d.
3. As appropriate, advance to FL diet
Continue CL restrictions (no caffeine, low sugar)
Give lactose free milk or fortified milk alternatives
Give 3-4 each 6oz protein shakes per RD recipe (each gives 150 cal, 24g Pro, 14g CHO
per 6oz)
4. Encourage sips of fluid throughout the day to meet FM goal of ~2500 Ml/d
5. RD to follow adequacy of PRO intake with min goal of 60-80g/d
6. RD to provide initial RYGB teaching
 CL/FL diet, supplementation, fluid needs (S/S of dehydration), protein sources, S/S of
intolerance, dumping syndrome and portion size.
7. Rec consider pt consult
8. Will follow glucose tread through labs
9. RD follow up POD3

Plan: Follow up with patients status after surgery. Assessment of any current changes in intake and
condition will be taken at this time.

Anticipated D/C Needs: Pt will require continuous counseling and supplementation through
Womans One A Day for up to three months post-op. When ready, pt will begin physical therapy to
start recovery and decrease sedentary lifestyle. Follow up with RD prior to discharge and once a
month for three months after discharge to discuss pts intake and tolerance of pureed food diet.

Emily Glass, Nutrition Student

100 Harborside Blvd
Providence, RI 02905
860-428-7812
 Menu for Gastric Bypass Case - Case Study 4

7:00 am 7:45 am
cup Grits
Cooked in water with 1/8t pepper, 1/16t salt, 1/8tgarlic powder and 1/8t paprika
cup low fat ricotta cheese

8:15 am 9:30 am
6 oz protein shake 27g chocolate whey protein mixed with 6 oz water and blended with 1 oz
fresh strawberry puree

9:45 am 11:30 am
1 Tablet One A Day: Womens formula
8 oz Brewed black tea

11:45 am 12:30 pm
2 oz Chicken Burger
Blenderized Chicken cooked in 1 tablespoon of olive oil until fork tender with 1/16t salt,
pepper, 1/4t Italian seasoning, and 1/8t onion powder
cup broccoli
Steamed in water, mashed with a fork and mixed with 1/8t lemon pepper

12:45 pm 1:30 pm
6 oz Protein shake- 27g Vanilla Protein powder mixed 6 oz water blended and blended with
cooked spinach

1:45 pm 3:30 pm
8 oz water, small sips

4:30 pm 5:30 pm
2.5 oz Orange Ginger Salmon
Blenderized salmon cooked until fork tender in 2.5T orange juice with 1/8t pepper
and 1/8t ground ginger.
cup green beans
Steamed in chicken broth with 1/8t salt and 1/8t pepper

6:15 pm 7:00 pm
1 Tablet One A Day: Womens formula
8 oz water, small sips

7:30 pm 8:15 pm
cup Sugar free vanilla pudding
cup mashed fresh bananas

8:45 pm - 9:30 pm+

8 oz Grape Powerade Zero, with small sips of water
Prepared For: Date:

Prepared By: Contact:

Bariatric Surgery Vitamin and Mineral Supplements

For the first month after bariatric surgery, you need to have chewable or liquid vitamins and minerals.
After 1 month, you can switch to pills. Most other medications are designed to dissolve easily, but
vitamins and minerals do not. So while you are healing, it is best to take chewable supplements. The
types of vitamins and minerals you will need are listed below.

Multivitamin with iron

Buy only from the following list of Complete with Iron vitamins.

Pokemon Complete with Iron

Flintstones Complete

Centrum Childrens Complete with Iron

Centrum Adult Chewable Vitamins or Centrum Liquid

CVS Spectravite Chewable or Liquid

Walgreens Complete Multivitamin Multimineral Supplement Liquid

Since you will be taking 2 multivitamins a day, you will need at least 60 chewable
tablets for the first month.

Vitamin B-12

Buy sublingual (melts under your tongue) vitamin B-12.

You need 350 to 500 micrograms (mcg) of vitamin B-12 per day oral/sublingual or nasal
or 1,000 micrograms per month intramuscularly.

Do not buy time release.

You can take vitamin B-12 once a day. You do not need to spread out the doses.
 Vitamin D-3

The amount of vitamin D recommended is 3,000 IU a day. Vitamin D can be found in

liquid or in gel caps.

You can take vitamin D-3 once a day. You do not need to spread out the doses.

Calcium citrate with vitamin D

Purchase a calcium supplement that contains vitamin D.

The amount of calcium you need:

Men and premenopausal women: 1,200 milligrams (mg) a day.

Postmenopausal women: 1,500 milligrams a day.

Do not take your other vitamins at the same time as your calcium citrate supplements. Calcium and iron
(in themultivitamin) compete for absorption. It is best to take your vitamins a couple of hours apart
from your calcium.

It is also important that you spread out your doses when you take your calcium supplements. For better
absorption, the doses should be taken at least 2 hours apart. It is best to take your calcium supplements
with meals.

Copyright Academy of Nutrition and Dietetics. This handout may be duplicated for client
education.