ADIME

A : (Assessment) (Formerly O of SOAP Format) (5pts):

Age: 48

Gender: Female

Dx: Nissen Fundoplication Surgery

The Nissen Fundoplication Surgery is the new gold standard for treating chronic GERD
when symptoms are not controlled by diet and medications.
The procedure involves wrapping the fundus of the stomach around the distal esophagus;
in doing so the surgeon increases the pressure of the LES preventing backflow of
stomach acids into the esophagus. During the procedure the surgeon fixes the hiatal
hernia if it is present

Complications include gas build up, abdominal pain and bloating, as gas is less able to
escape through the LES
Patients should be nutritionally treated similarly to a patient with gastric bypass, but less
restrictive, as they did not lose as much of their stomach volume.
PMHx:
chronic GERD related to Hiatal Hernia, and previous ulnar and shoulder surgeries
The patients chart didnt include PMHx, so I relied only upon medical conditions the
patient informed me of. She is currently on a bronchodilator and levothyroxine, so it is
possible that she could have issues with asthma or hypothyroidism.
Treatments/Therapies/Alternative Medicine (chemo, radiation, dialysis, acupuncture)
-Speech therapist to have a barium swallow done to see how the surgery affects swallow
function
Ht: 5 152.4
Wt:103 lb, 46.8 kg
IBW: 100 lb +/- 10 lb (90-110)
%IBW: 103%
UBW: 106
%UBW: 97%
BMI: 20.4
Wt changes while in hospital: none; 3 lbs. lost prior to admission within 1 month
Nutl Requirements: (5pts)
kcal: Mifflin St Jeor X 1.4 = 1432 kcal

kcal/kg = 30 kcal/kg = 1404 kcal

Protein gm/kg = 1.2-1.4 g/kg = 56.16 g- 65.5 g
Fluid = 30 cc/kg = 1404 cc
Other nutrients as deemed necessary (Fe, fiber, Na etc)
With the Nissen Fundoplication Procedure, the patient should actually avoid fiber and
highly seasoned foods (limit Na); at least to start; can slowly reintroduce foods as long as
they dont exacerbate GERD symptoms
Based on lab values, patient needs adequate Fe in her diet to treat potential anemia (low
Hgb, Hct, MCV)
Diet Order: (Current and others in chronological order) (5pts):
Current: Full Liquid
Previous: NPO before and after Nissen Fundoplication surgery
Assessment of Appropriateness of current diet order: This diet order is appropriate if
the patient tolerates it. At the time of my visit, she had just ordered her first food: cream
of wheat. If she tolerates this, it is appropriate and she can slowly add soft solid foods.
If the full liquids arent tolerated, the patient should change to a clear liquid diet.
Labs: (5pts) Explain relevant lab values both normal and abnormal
Hgb

9.5 L

Hct

29.9 L

MCV

66 L

Na

142

4.8

Glucose

63 L

BUN

11

GFR

107

Cre

0.63

Alb

3.2 L

Alk phos

40 L

Low hemoglobin; indicated

potential anemia
Percentage of RBC lower than
normal, indicates anemia
Microcytic anemia; indicates iron
deficiency
Na within normal limits; good
electrolyte control
K within normal limits; good
electrolyte control
Low glucose levels; expected due
to prolonged NPO for surgery
Kidneys functioning normally; can
tolerate protein and solute load
Kidneys functioning normally; can
tolerate protein and solute load
Kidneys functioning normally; can
tolerate protein and solute load
Low; could be due to
inflammation from surgical site
Decreased Alk phos related to
zinc deficiency, malnutrition or
protein deficiency (could be from

BP

116/75

restricted diet due to pain when

eating)
Within normal limits

Meds: (5pts)
Ketorlac Tromethamin
(toradol)
Albuterol
Morphine
Enoxaparin (lovenox)
Odanestron (Zofran)
Levothyroxine (synthroid)

Pantoprozole (protonix)

NSAID: can cause fluctuations in weight,

hyperglycemia, hyperkalemia, hyponatremia
Bronchodilator- can increase appetite OR be related to
potential anorexia; should limit caffeine and xanthine
intake
Pain management; can lead to weight loss, increased
thirst, and dehydration
Anticoagulant; Should consume consistent Vitamin K
from food daily; may cause N/V which could decrease
appetite and is related to constipation
Thyroid hormone; Can decrease absorption of Fe, Ca,
or Mg supplements; Soymilk, soy, walnuts, cottonseed
meal, high fiber foods. Caution with grapefruit and
related citrus
AntiGERD; Can decrease the absorption of Fe and
B12; can decrease calcium absorption. May advise
Calcium supplementation, avoid gingko as it decreases
drug level; additional dietary Fe and B12 or
supplementation may be recommended, but should be
taken separately from protonix

Nutrition Focused Physical Findings: (obesity, cachexia, decubitus, mental status)

(5pts)
Patient looked thin under her blankets, but did not show signs of cachexia. Skin intact;
proper color and appeared hydrated. Overall healthful appearance
Pertinent Social Hx: (5pts)
Patient is primary cook in the household; prepares most of her meals herself
No other social history known, as patients chart information was limited- only
information pertinent for the surgery was included in her medical record
Nutrition History, Diet PTA (5pts)
The patient cooks for herself. She doesnt eat a big breakfast, mostly nuts and fruit.
Patient cooks dinner for herself, which most often consist of some type of chicken and
pasta dish or beef tacos. For lunch, she will eat leftovers from dinner or will have a soup
including tomato-based soups. Patient drinks about 1-2 cups of coffee per day.

Summary of Current Intake (5pts)

Before the surgery, the patient didnt eat much (<50% meals) because everything she ate
resulted in heartburn. Currently, the patient is not eating, as her diet order was NPO for
surgery. She will soon introduce a full liquid diet if tolerated. The full liquid diet at MMH
consists of cream of wheat, milks, yogurts, cream of corn or mushroom soup, sherbet,
and ice creams
D (Diagnosis) (5pts) PES
Nutritional Problem/Diagnosis Related To Etiology As evidenced By
Signs/Symptoms
Food and Nutrition related knowledge deficit related to lack of prior nutrition-related
education as evidenced by lack of knowledge about the Nissen Soft diet (will discuss in
addendum)
I (Intervention) (15 pts) Stems from Nutritional Diagnosis and Etiology and must
determine patient-focused expected outcomes for each nutrition diagnosis
Organized into 4 categories: (Include only categories that pertain to your patient)
Food and/or Nutrient Delivery (meals, snacks, enteral and/or parenteral feeding;
supplements as in commercial, food/drink based, or vitamin/mineral)

Recommend that the patient continues to consume full liquid diet if it is tolerated
and recommend a switch to a clear liquid diet if it is not
Recommend the patient follow a Nissen Soft diet (which I will talk more about in
the addendum section) after she tolerates full liquid for a day or two
Advise the patient to consume small, frequent meals
Recommend that the patient avoids any foods that continue to upset her GERD
symptoms
Recommend that the patient drinks her fluids between meals, or limits beverage
consumption during meals to <4 oz to avoid overstretching stomach

Nutrition Education (purpose; priority modifications; survival info; nutrition

relationship to health and disease; recommended modifications)
Educate patient on Nissen Soft Diet (meal pattern, meal sizes, foods to consume,
foods to avoid)
Inform patient about how and when she should introduce new foods to see if they
exacerbate her GERD symptoms
Educate patient on the progression of full liquid to Nissen soft diet
Inform the patient about the importance of consuming small frequent meals in
order to prevent stretching out the stomach
Coordination of Nutrition Care (team meeting; referral to RD with different expertise;
collaboration with other providers; referral to community agencies or programs)

Coordinate with the diet office to educate diet-techs about what foods should be
avoided specifically with Nissen-soft diet (for example, full liquid diet allows for
chocolate ice cream and pudding, but after the Nissen fundoplication patients
should avoid all chocolate)
Coordinate with the SLP, as the nature of the Nissen fundoplication could cause
challenges with swallowing
Referral to a specialty GI RD to educate the patient more about Nissen soft diet

Nutrition Counseling (as in theories, strategies-not used in acute care)

M/E Monitoring and Evaluation (10pts) Nutrition care indicators that will reflect a
change in nutrition care provided
Organized into 4 categories: (Include only categories that pertain to your patient)
Food/Nutrition Related Outcomes (Food intake, supplement use)
Monitor patient to see that she is tolerating full liquid
o Check for bloating, abdominal discomfort, diarrhea
o If the patient is tolerating full liquid advance to Nissen soft
o If the patient isnt tolerating regress to clear liquid
Monitor food intake and evaluate whether or not the patient requires a supplement
Patient should consume >75% of meals
Anthropometric Measurement Outcomes (Ht, Wt, BMI)
Monitor weight; patient should not lose any more weight
Biochemical Data, Medical Tests, and Procedure Outcomes (glucose, electrolytes,
gastric emptying)

Evaluate patients Hgb, Hct, and MCV

o Potentially include an iron supplement if the values do not improve after
implementing Nissen Soft diet

Nutrition-Focused Physical Findings Outcomes (physical appearance, muscle/fat

wasting, swallow function, appetite)

Evaluate patient to ensure that no muscle/fat wasting occurs

Monitor patients appetite and willingness to eat the foods prescribed within the
Nissen soft diet

Nutrition Education Outcomes Knowledge based, pt able to state 3 prepared foods

high in Na)
Pt able to describe how often she should eat, and the approximate size of her
meals
Pt able to identify foods that should be avoided while on the Nissen-Soft diet

ADDENDUM TO ADIME
Students must attach:
1. For current Dx (5pts) - MNT, Foods Allowed, Foods Not
Allowed, Diet Instruction Materials if appropriate. Describe in
your own words the rationale for diet restrictions/modifications
Nissen Fundoplication Surgery related to severe GERD and a
hiatal hernia
o Patients who undergo the Nissen Fundoplication surgery
should follow a full-liquid diet then proceed to the Nissen
soft diet
o Avoid foods that can exacerbate GERD symptoms (tomato
products, chocolate, caffeine, very high fiber foods and
highly seasoned foods)
o After the surgery, the patient should avoid stretching the
stomach by eating small frequent meals and only
consuming cup of fluid during meals and only 1 cup
between meals or with small snacks
o To prevent GERD symptoms, eat slowly, and eat sitting
upright
o Avoid creating large boluses to pass into the stomach- take
small bites and avoid crusty breads and sticky foods that
form a large bolus after being chewed (bananas, rolls,
doughnuts, bagels)
o If eating bread- it should be toasted
o Sweets can induce dumping syndrome as they are rapidly
digested and moved onto the small and large intestinesshould be consumed in moderation
o Avoid gas by not drinking through a straw and avoiding
carbonated beverages. Limit gas-producing foods such as
broccoli, beans, cauliflower, corn, etc
o Overall a list of foods to limit or avoid include: chocolate,
alcohol, caffeine, citrus juices, untoasted brads, high fiber
foods or very coarse grains, fresh or dried fruit (canned is
okay if not sweetened), highly seasoned products, high fat
foods (bacon, fried eggs, ham fat, lard), nuts, tough meats,
tomato products, gas-producing foods, raw vegetables,
sweets, chocolate, and ANY OTHER FOOD that is not well-

tolerated
2. Pertinent Drug/Nutrient Interaction Information if NOT
addressed in note (5pts)
Mentioned above in the note

3. Menu Plan or Nutrition Support Regimen for Discharge Diet

If Appropriate. Must be of your own design. Include pertinent
nutrient analysis (10 pts)
Kcal
Meal one
unsweetened canned
peaches 1 C
4 oz vanilla yogurt

CHO
g

Pro
g

Fat g

Fibe
rg

Na
mg

Fe
mg

59
96

15
16

1
6

0
1

3
0

7
75

1
0

Meal two
toasted white bread
2 Tbsp peanut buttter
(creamy)

69

13

177

195

17

114

Meal three
Baked sweet potato
(skin peeled)
2 oz ground turkey

101
123

23
0

2
15

0
7

4
0

41
240

1
1

Meal four
2 oz beef burger
white rice 1 cup

130
204

0
44

15
4

8
0

0
1

39
2

2
2

69
95

13
2

2
5

1
7

1
0

177
372

1
0

117

19

495

Meal five
1 piece toasted white
bread
1 oz american cheese
1 cup canned baby
peas

Meal six
4 oz milk 1%
1 cup cheerios

51
110

6
22

4
3

1
2

0
3

54
200

0
10

Total

141
9

178

75

46

23

1993

21

This day provides adequate calories and protein

Protein was slightly over, but kidney function is adequate
The fiber was kept relatively low to prevent gas and constipation
Sodium was kept below 2000 mg simply because the patient cannot
tolerate highly seasoned foods
The patient is receiving adequate iron (>18 mg/day) in this sample
meal plan; should help with low Hgb, Hct, MCV values
Fluids: 1400 cc prescription = 47 oz
If patient consumes 4 oz fluid with every meal and between every meal
(12x/day), she will meet fluid needs without overstretching stomach

4. References (5 pts)
Mahan, L. Kathleen., Sylvia Escott-Stump, Janice L. Raymond, and Marie V.
Krause. Krause's Food & the Nutrition Care Process. St. Louis, MO:
Elsevier/Saunders, 2012. Print.
Pronsky, Zaneta M., and Jeanne P. Crowe. Food Medication Interactions.
Birchrunville, Penn.: Food-Medication Interactions, 2010. Print.
"ENCPT." Welcome to the Academy of Nutrition and Dietitics. The Academy of
Nutrition and Dietetics, n.d. Web. 14 Apr. 2016. <https://ncpt.webauthor.com/>.
"RBC Indices: MedlinePlus Medical Encyclopedia." U.S National Library of
Medicine. U.S. National Library of Medicine/National Institute of Health, n.d. Web.
14 Apr. 2016. <https://www.nlm.nih.gov/medlineplus/ency/article/003648.htm>.
"Diet After Nissen Fundoplication Surgery." Diet After Nissen Fundoplication
Surgery. UPMC, n.d. Web. 14 Apr. 2016. <http://www.upmc.com/patientsvisitors/education/nutrition/pages/diet-after-nissen-fundoplication-surgery.aspx>.
"Vitamins and Minerals." Vitamins and Minerals. USDA, n.d. Web. 14 Apr. 2016.
<https://fnic.nal.usda.gov/food-composition/vitamins-and-minerals>.
"Anti-reflux Surgery: MedlinePlus Medical Encyclopedia." U.S National Library of
Medicine. U.S. National Library of Medicine, n.d. Web. 14 Apr. 2016.
<https://www.nlm.nih.gov/medlineplus/ency/article/002925.htm>.