1. Surgery and Nutritional Support
Chapter 22
Surgery and Nutritional Support
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2. Chapter 22
Lesson 22.1
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3. Key Concepts
Surgical treatment requires added nutritional support for tissue healing and rapid recovery.
Diet management for surgery patients to ensure optimal nutritional support involves both oral and intravenous feeding methods.
Why would surgery require special nutritional support?
What health care team members are involved in nutritional support for surgery patients?
What are the various roles of the surgeon, clinical nutritionist, pharmacist, and nursing staff?
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4. Nutritional Needs of General Surgery Patients
Nutritional needs are greatly increased in patients undergoing surgery.
Deficiencies can easily develop.
Pay careful attention to:
Nutritional status pre-surgery
Individual nutritional needs post-surgery
How can nutritional status be assessed preoperatively?
Why is it important to consider nutritional status before surgery? During recovery?
What relationship do age and general health status have on nutritional care?
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5. Poor Nutritional Status
Associated with:
Impaired wound healing, immune system
Increased risk of postoperative infection
Reduced quality of life
Impaired function of gastrointestinal tract, cardiovascular system, respiratory system
Increased hospital stay, cost, mortality rate
What nutrients are related to wound healing?
How is nutrition related to immune function?
What postoperative complications can be reduced with adequate nutritional care?
How does nutritional status affect a patient’s quality of life?
How does adequate nutritional status keep health care costs down?
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6. Preoperative Nutritional Care: Nutrient Reserves
Nutrient reserves can be built up prior to elective surgery to fortify a patient
Protein deficiencies are common
Sufficient kilocalories are required
Extra carbohydrates maintain glycogen stores
Vitamin/mineral deficiencies should be corrected
Water balance should be assessed
What is protein-energy malnutrition (PEM)? How is it defined? Why are older adults especially at risk?
Why is extra protein so important? (to counteract blood loss during surgery, prevent tissue breakdown, and promote bone healing following surgery)
What are examples of high-protein foods or drinks?
Describe a sample preoperative menu for increasing protein reserves.
Why are adequate carbohydrates necessary when building protein stores?
What relationship do vitamins and minerals have to protein balance?
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7. Immediate Preoperative Period
Patients are typically directed not to take anything orally for at least eight hours prior to surgery.
Prior to gastrointestinal surgery, a nonresidue diet may be prescribed.
Nonresidue elemental formulas provide complete diet in liquid form.
Why is it recommended to avoid eating eight hours before surgery? (to prevent aspiration of food during anesthesia and to prevent complications due to food in stomach)
What can aspiration cause?
How does anesthesia contribute to risk of aspiration?
What complications could occur with food in the stomach during surgery?
What are the implications for emergency surgery?
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8. Nonresidue Diet
Diet includes only those foods that are free of fiber, seeds, and skins.
Prohibited foods include fruits, vegetables, cheese, milk, potatoes, unrefined rice, fats, and pepper.
Vitamin/mineral supplements are required for prolonged nonresidue diet.
Examples of foods to include in a nonresidue diet:
Crackers, melba toast, Cream of Wheat, cornflakes, Rice Krispies, pasta
Plain cakes and cookies, gelatin desserts, water ices
Hard-boiled eggs, tender beef, chicken, fish, lamb, liver, veal
Salt; clear soups, carbonated beverages, coffee, tea
What nutrients might be lacking in these allowable foods? Would supplements be indicated?
What benefits does a nonresidue diet offer?
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9. Postsurgical Nonresidue Diet
Nonresidue diet plus:
Processed cheese, mild cream cheeses
Potatoes
Bread without bran
All desserts except those containing fruit and nuts
Condiments as desired
When can additional foods be introduced? Why?
How might the introduction of these foods enhance appetite and caloric intake?
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10. Postoperative Nutritional Care: Nutrient Needs for Healing
Postoperative nutrient losses are great, but food intake is diminished.
Protein losses occur during surgery from tissue breakdown and blood loss.
Catabolism usually occurs after surgery (tissue breakdown and loss exceed tissue buildup).
Negative nitrogen balance may occur.
Why is a nutritional deficit resulting in weight loss a risk following surgery?
Compare and contrast catabolism and anabolism.
What results from a negative nitrogen balance?
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11. Need for Increased Protein
Building tissue for wound healing
Controlling shock
Controlling edema
Healing bone
Resisting infection
Transporting lipids
What protein components are essential for tissue building?
How does plasma protein contribute to blood volume and edema?
What is the relationship between protein and bone repair? What vitamins and minerals are also necessary for bone healing?
What are lymphocytes and how do they relate to immune function?
Why is infection a secondary complication of many surgeries? How can adequate nutrition reduce this risk?
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12. Problems Resulting From Protein Deficiency
Poor healing of wounds and fractures
Rupture of suture lines (dehiscence)
Depressed heart and lung function
Anemia, liver damage
Failure of gastrointestinal stomas to function
Reduced resistance to infection
Extensive weight loss
Increased mortality risk
How can protein cause wound dehiscence?
Why is anemia a risk?
What is the overall effect of nutrition on length of hospital stay, morbidity, and mortality rates?
Why would liver damage occur? Why is it important to have a balance of nutrients?
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13. Other Postoperative Concerns
Ensure sufficient fluids to prevent dehydration
Provide sufficient nonprotein kcalories for energy in order to spare protein for tissue building
Ensure adequate vitamins
Ensure adequate potassium, phosphorus, iron, zinc
Avoid electrolyte imbalances
How is dehydration postoperatively assessed?
How many daily grams of carbohydrates are needed to spare protein for tissue building?
Vitamins required include:
Vitamin C to build connective tissue
B vitamins to metabolize protein and energy
B-complex vitamins to build hemoglobin
Vitamin K to promote blood clotting
How do minerals affect fluid balance and wound healing?
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14. Initial Intravenous Fluid and Electrolytes
Oral feeding is encouraged soon after surgery.
Routine postoperative intravenous fluids supply hydration and electrolytes, not kcalories and nutrients.
Why is oral feeding the preferred method?
When can foods be reintroduced after surgery?
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15. Methods of Feeding
Enteral: nourishment through regular gastrointestinal route, either by regular oral feedings or by tube feedings
Parenteral: nourishment through small peripheral veins or large central vein
What are examples of enteral and parenteral routes?
What complications are associated with either of these methods of feeding?
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16. Oral Feeding Allows more needed nutrients to be added
Stimulates normal action of the gastrointestinal tract
Can usually resume once regular bowel sounds return
Progresses from clear to full liquids, then to a soft or regular diet
How do these benefits compare to parenteral routes?
How soon should oral feedings begin?
What nursing assessments are important regarding oral feeding after surgery?
What are aspiration precautions?
What does NPO mean?
Individual tolerance and needs serve as the guide.
Frequent small meals may be advised.
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17. Tube Feeding Used when oral feeding cannot be tolerated
Nasogastric tube is most common route
Nasoduodenal or nasojejunal tube more appropriate for patients at risk for aspiration, reflux, or continuous vomiting
(Cont'd…)
How are nasogastric tubes inserted? Is this a nursing action?
How is aspiration minimized?
How is proper tube placement confirmed?
How can comfort be maximized for the patient?
Why is dry mouth a problem? What are nursing interventions?
What is a common side effect of nasogastric feedings?
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18. Tube Feeding Compare and contrast the different types of tube feeding.
What is stoma care?
What is mouth care?
What psychosocial considerations are there with tube feedings? What role does food play in a person’s quality of life?
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19. Alternate Routes for Enteral Tube Feeding
Esophagostomy
Percutaneous endoscopic gastrostomy (PEG)
Percutaneous endoscopic jejunostomy (PEJ)
Why would these alternate routes be indicated?
How are they inserted?
What are potential complications?
What are nursing care actions and goals?
How do nasogastric tubes differ from PEG or PEJ tubes?
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20. Tube-Feeding Formula Generally prescribed by the physician
Important to regulate amount and rate of administration
Diarrhea is most common complication
Wide variety of commercial formulas available
Name examples of products used for tube feedings.
Why is amount and rate regulation important?
Why should skin care be addressed?
Are feeding pumps used?
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21. Parenteral Feeding Routes
Peripheral parenteral nutrition (PPN): uses less concentrated solutions through small peripheral veins when feeding is necessary for a brief period (10 days)
Total parenteral nutrition (TPN): used when energy and nutrient requirement is large or to supply full nutritional support for long periods of time through large central vein
How do PPN and TPN concentrations differ?
What are the psychosocial issues to consider?
What conditions might require parenteral feedings?
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22. Peripheral Parenteral Nutrition
What type of catheters are used?
What type of intravenous care is required?
What veins can be used for PPN?
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23. Catheter Placement for TPN
Who inserts a catheter for TPN administration?
Why is the subclavian vein used versus a peripheral vein?
How should the intravenous site be cared for?
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24. Example of Basic TPN Formula Components
How does TPN compare to other intravenous fluids?
Why would insulin or heparin be added?
How is TPN stored?
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25. Administration of TPN Formula
How is patient response to TPN assessed?
Can an LPN/LVN administer TPN?
What are the risks associated with TPN?
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26. Chapter 22
Lesson 22.2
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27. Key Concept
The special nutritional problems of gastrointestinal surgery require diet modifications because of the surgery’s effect on normal food passage.
What challenges might gastrointestinal surgery present nutritionally?
Describe normal gastrointestinal function and how it is altered during and after surgery.
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28. Nutrition after Gastrointestinal Surgery
Gastrointestinal surgery requires special nutritional attention
Nutrition therapy varies, depending on the surgery site
Sites of gastrointestinal surgery include the mouth, throat, and neck, stomach, gallbladder, intestines, or rectum.
What are some causes for mouth, throat, and neck surgery? Stomach surgery? Gallbladder surgery? Rectal surgery?
Name some risk factors for these various types of surgeries.
What are the different nutritional implications for these surgeries?
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29. Mouth, Throat, and Neck Surgery
This surgery requires modification in the mode of eating.
Patients cannot chew or swallow normally.
Oral liquid feedings ensure adequate nutrition.
Tube feedings are required for radical neck or facial surgery.
Why might depression be a component of the disease process?
What nursing interventions can promote adequate nutrition and psychosocial adjustment?
What is the role of saliva in digestion?
Review side effects and nursing care for tube feedings.
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30. Stomach Surgery
Because the stomach is the first major food reservoir in the gastrointestinal tract, stomach surgery poses special problems in maintaining adequate nutrition.
Problems may develop immediately after surgery or after regular diet resumes.
Describe causes for stomach surgery and its incidence.
Review the anatomy and physiology of the stomach in relationship to the entire gastrointestinal system.
Why is gastric surgery challenging from a nutritional perspective?
How can nurses use a holistic model of care to support a patient following stomach surgery?
What problems would you expect following gastric surgery or during the extended recovery period?
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31. Types of Procedures
Compare and contrast the different procedures shown in Figure 22-4.
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32. Immediate Postoperative Period
Increased gastric fullness and distention may result if gastric resection involved a vagotomy (cutting of the vagus nerve).
Weight loss is common.
Patient may be fed via jejunostomy.
Frequent small, simple oral feedings are resumed according to patient’s tolerance.
Possible results of vagotomy: Stomach empties poorly, allowing food to ferment; this can lead to gas and diarrhea.
What is a function of the vagus nerve?
What does the term “atonic” refer to?
What does food fermentation lead to?
What is a jejunostomy? How is it cared for? Is it temporary?
How should feedings progress?
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33. Dumping Syndrome
Frequent complication of extensive gastric resection in which readily soluble carbohydrates rapidly “dump” into small intestine
Symptoms include:
Cramping, full feeling
Rapid pulse
Wave of weakness, cold sweating, dizziness
Nausea, vomiting, diarrhea
Occurs 30 to 60 minutes after meal
Results in patient eating less food
Why are shock symptoms present?
Is anxiety a complication of dumping syndrome?
How does this syndrome lead to weight loss?
Define higher osmolality and describe its implications.
How are blood glucose levels affected in dumping syndrome?
Once dumping syndrome is stabilized, how is dietary tolerance tested?
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34. Diet for Postoperative Gastric Dumping Syndrome
Five or six small meals daily
Relatively high fat content, low simple carbohydrate content, low-roughage foods, high protein content
No milk, sugar, alcohol, or sweet sodas; no very hot or very cold foods
Fluids avoided one hour before and after meals; minimal fluids during meals
What is the advantage of small, frequent meals?
Why is fat an important component?
What is high-quality protein?
Why should simple carbohydrates be restricted?
What are examples of low-roughage foods?
What position is recommended after meals to prevent dumping syndrome?
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35. Gallbladder Surgery Cholecystectomy is the removal of the gallbladder.
Surgery is minimally invasive.
Some moderation in dietary fat is usually indicated after surgery.
Depending on individual tolerance and response, a relatively low-fat diet may be needed over a period of time.
Where is the gallbladder located?
What is its function?
Why is a low-fat diet recommended?
Describe how surgical advances have changed for cholecystectomy.
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36. Gallbladder with Stone
Why do stones form?
What is the common bile duct?
How can stones damage the intestine?
What are presenting signs for cholelithiasis?
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37. Intestinal Surgery
Intestinal resections are required in cases involving tumors, lesions, or obstructions.
When most of the small intestine is removed, TPN is used with small allowance of oral feeding.
Stoma may be created for elimination of fecal waste (ileostomy, colostomy).
Why is TPN required if most of small intestine is removed?
In less severe cases, a low-fiber diet may be used briefly.
Provide an example of a low-fiber diet.
The goal is to advance to a regular diet.
How does a regular diet impact quality of life and psychosocial adjustment?
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38. Ileostomy and Colostomy
How do ileostomy and colostomy differ?
What is a stoma?
How are a stoma and peristomal skin cared for?
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39. Rectal Surgery
Clear fluid or nonresidue diet may be indicated after surgery to reduce painful elimination and allow healing.
Return to a regular diet is usually rapid.
What is a hemorrhoidectomy?
Describe items included in a clear liquid diet.
What is a nonresidue diet? What items are contraindicated when on a nonresidue diet?
Provide an example of a nonresidue commercial formula.
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40. Nutritional Needs for Burn Patients
Tremendous nutritional challenge
Plan of care influenced by:
Age
Health condition
Burn severity
Plan constantly adjusted
Critical attention paid to amino acid needs
Why is nutritional support a challenge in caring for the burn patient?
Why are amino acid needs so important at each stage? (for tissue rebuilding, fluid-electrolyte balance, energy [kcalorie] support)
What are special considerations regarding children and older adults who experience third-degree burns?
Describe the specialized features of a burn center. Who has a burn care facility in their community?
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41. Degree and Extent of Burns
What structures are affected by each type of burn?
What is the appearance of each type of burn?
How is body surface area calculated?
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42. Stages of Nutritional Care of Burn Patients
Stage 1, Part 1: Immediate Shock Period
Immediate loss of water, electrolytes, protein
Immediate intravenous fluid therapy with salt solution administered
Albumin solutions or plasma used after 12 hours to restore blood volume
Little attempt made to meet protein and energy requirements
(Cont'd…)
Why does shock occur in relationship to burn injury?
What types of intravenous fluids are indicated and why?
How does albumin affect blood volume?
How are albumin levels monitored? What are normal values?
Why is the focus at this stage not on nutritional and energy needs?
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43. Stages of Nutritional Care of Burn Patients
(…Cont’d)
Stage 1, Part 2: Recovery Period
Tissue fluids and electrolytes are gradually reabsorbed after 48 to 72 hours.
Diuresis indicates successful initial therapy.
Constant attention to fluid intake and output remains essential.
(Cont'd…)
What is diuresis? How is it assessed?
What are signs of dehyrdration? Overhydration?
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44. Stages of Nutritional Care of Burn Patients
(…Cont’d)
Stage 2, Part 1: Secondary Feeding Period
Adequate bowel function returns after seven days.
Life depends on rigorous nutrition therapy.
Protein and electrolytes lost through tissue destruction must be replaced.
Lean body mass and nitrogen are lost through tissue catabolism.
Increased metabolism occurs.
Increased energy is needed.
(Cont'd…)
When can oral feedings be introduced?
What coexisting problems (e.g., depression) present challenges to nutritional status?
For what reasons are high-protein, high-energy diets required to treat burn patients?
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45. Stages of Nutritional Care of Burn Patients
(…Cont’d)
Stage 2, Part 2: Nutrition Therapy
High protein intake
High energy intake
Caloric needs based on total body surface area burned
Liberal portion of kcalories from carbohydrates
Avoid overfeeding
High vitamin and mineral intake
(Cont'd…)
How are protein requirements calculated for burn patients?
Why is overfeeding a concern?
What is a recommended ratio of nutrients at this stage?
Which vitamins and minerals are needed? (vitamins A and C, zinc, thiamin, riboflavin, niacin)
Pay close attention to electrolytes and calcium: phosphorus ratios.
How do vitamins and minerals relate to tissue healing?
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46. Stages of Nutritional Care of Burn Patients
(…Cont’d)
Stage 2, Part 3: Dietary Management
Enteral feeding
Solid foods based on individual preferences
Concentrated liquids with added protein or amino acids
Calculated tube feedings when required
Parenteral feeding
When enteral feeding is impossible or inadequate
(Cont'd…)
How is intake and output documented?
What type of feeding method is preferred? What are the advantages and disadvantages of each method?
Are commercial formulas used as supplements during this stage? Provide examples of formula supplements.
Following a burn injury, when are solid foods usually tolerated?
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47. Stages of Nutritional Care of Burn Patients
(…Cont’d)
Stage 3: Follow-up Reconstruction
Continued nutritional support to maintain tissue strength for successful grafting or reconstructive surgery
How does stress affect a person’s recovery and response to follow-up surgery?
How can a team approach improve a patient’s outcome with reconstructive surgery?
Relate how general nutritional concepts apply to reconstructive therapy.
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