1. Williams' Basic Nutrition & Diet Therapy
14th Edition
Chapter 22
Surgery and Nutrition Support
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2. Lesson 22.1: Nutrition Support and Methods of Feeding
Surgical treatment requires added nutrition support for tissue healing and rapid recovery.
To ensure optimal nutrition for surgery patients, diet management may involve enteral and/or parenteral nutrition support.
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3. Introduction (p. 447) Clinical signs of malnutrition in:
38.7% of hospitalized elderly patients
50.5% of elderly patients in rehabilitation facilities
Effective nutrition should:
Reverse malnutrition
Improve prognosis
Speed recovery
Malnutrition hinders healing.
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4. Nutrition Needs of General Surgery Patients (p. 447)
Nutrition needs are greatly increased in patients undergoing surgery
Deficiencies easily develop
Pay careful attention to:
Nutritional status before surgery
Individual nutrition needs after surgery
Proper nutrition after surgery is essential for wound healing and recovery.
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5. Poor Nutritional Status (p. 447)
Has been associated with:
Impaired wound healing
Increased risk of postoperative infection
Reduced quality of life, increased mortality rate
Impaired function of gastrointestinal tract, cardiovascular system, respiratory system
Increased hospital stay, cost
Ask students to explain how an impaired immune system, impaired wound healing, and an increased risk of infection are related.
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6. Preoperative Nutrition Care: Nutrient Reserves (p. 448)
Nutrient reserves can be built up before elective surgery to fortify a patient
Protein deficiencies are common
Sufficient kilocalories are required
Extra carbohydrates maintain glycogen stores
Vitamin and mineral deficiencies should be corrected
Water balance should be assessed
Why is extra protein so important? (To counteract blood loss during surgery, prevent tissue breakdown, and promote bone healing after surgery)
Describe a sample preoperative menu for increasing protein reserves.
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7. Immediate Preoperative Period (p. 449)
Patients are typically directed not to take anything orally for at least 8 hours before surgery
Before gastrointestinal surgery, a nonresidue diet may be prescribed
Nonresidue elemental formulas provide complete diet in liquid form
Why is it recommended to avoid eating 8 hours before surgery? (To prevent aspiration of food during anesthesia and complications from food in the stomach)
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8. Emergency Surgery (p. 449)
No time for building up ideal nutrient reserves
Reason for maintaining good nutrition status at all times
Following a healthy diet at all times ensures that one will have the nutrient status needed for urgent surgery.
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9. Postoperative Nutrition Care: Nutrient Needs for Healing (p. 449)
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)
Protein also may be lost through various body fluids or exudates.
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10. Need for Increased Protein (p. 450)
Building tissue for wound healing
Controlling edema
Controlling shock by maintaining blood volume
Healing bone: protein is essential
Resisting infection: protein tissues are major components of immune system
Transporting lipids: fat is important component of tissue structure
Ask students to identify some of the risks of protein deficiency after surgery. (Poor wound healing, rupture of the suture lines, delayed healing of fractures, depressed heart and lung function, anemia, failure of GI stomas, reduced resistance to infection, liver damage, extensive weight loss, muscle wasting, and increased risk of death)
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11. Water (p. 451) To prevent dehydration
Elderly require special attention
Large water losses possible from various routes
IV fluids
Oral fluids as soon as possible
Surgery disrupts fluid distribution in the patient, which can reduce circulation and hinder recovery.
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12. Energy (p. 451)
Provide sufficient nonprotein kilocalories for energy to spare protein for tissue building
Mifflin–St. Jeor equations:
Male: BMR = (10 × Weight in kg) + (6.25 × Height in cm) – (5 × Age in yr) + 5
Female: BMR = (10 × Weight in kg) + (6.25 × Height in cm) – (5 × Age in yr) – 161
Energy needs increased for extensive surgery or burn patients
Carbohydrates also help prevent liver damage by maintaining glycogen reserves in the liver tissue.
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13. Vitamins (p. 451) 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
These vitamins are important in wound healing.
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14. Minerals (p. 451) Potassium Phosphorus Sodium, chloride Iron Zinc
Zinc is particularly important in wound healing, and even patients consuming normally adequate amounts of zinc through the diet may benefit from zinc supplementation.
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15. General Dietary Management (p. 452)
Routine IV fluids supply hydration and electrolytes, but not energy and nutrients
Methods of feeding
Oral
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
Oral feedings are the method of choice when they can be tolerated.
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16. Methods of Feeding: Oral (p. 452)
Allows more needed nutrients to be added
Stimulates normal action of the gastrointestinal tract
Early feedings associated with reduced complications
Progresses from clear to full liquids, then to a soft or regular diet
Routine house diet
Assisted oral feeding: try to avoid making patient feel inadequate
What does “NPO” mean? (Nothing by mouth)
Individual tolerance and needs serve as the guide.
Frequent small meals may be advised.
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17. Methods of Feeding: Enteral (p. 454)
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
Modern small-bore feeding tubes are relatively comfortable for patients.
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18. Methods of Feeding (p. 456) Types of enteral feeding.
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19. Alternative Routes (p. 455)
Esophagostomy
Percutaneous endoscopic gastrostomy
Percutaneous endoscopic jejunostomy
The nasoenteric route is used for short-term feedings, but these alternative routes are more comfortable for long-term feeding.
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20. Alternative Route Formulas (p. 456)
Generally prescribed by the physician
Important to regulate amount and rate of administration
Wide variety of commercial formulas available
Rate: bolus or continuous
Monitoring for complications: diarrhea is most common complication
Adding fiber-rich formulas may improve bowel function and help reduce diarrhea.
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21. Parenteral Feedings (p. 458)
Definition: any method other than the normal GI route
Peripheral parenteral nutrition: less than 5 to 7 days
Total parenteral nutrition: for large nutrient needs or longer periods
Must be discussed with patient and/or family first
These methods are used when the patient cannot tolerate food or formula through the GI tract.
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22. Case Study
Mrs. White is a 76-year-old female who recently had a stroke. She has a functioning GI tract. The physician has recommended a PEG tube be placed for long-term feeding. Mrs. White will soon be transferred to a long-term care facility.
Case Study:
Mrs. White is a 76-year-old female who recently had a stroke and is unable to swallow effectively. The physician has recommended a PEG tube be placed for long-term feeding. Mrs. White will soon be transferred to a long-term care facility.
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23. Case Study (cont’d)
Evaluate appropriateness of recommended feeding route.
What evaluation criteria should be considered or what additional questions should be asked?
A PEG tube is a percutaneous gastrostomy tube and is placed endoscopically through the abdominal wall into the stomach.
A person should not be a risk for aspiration.
Criteria may consist of such factors as the need for a long-term feeding, risk of aspiration, current nutritional status.
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24. Case Study (cont’d)
Is parenteral nutrition more appropriate for Mrs. White? Why or why not?
No, parenteral feeding is used when the gastrointestinal tract cannot be used. In this case, Mrs. White has had a stroke and has a functioning GI tract.
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25. Peripheral Parenteral Feeding (p. 459)
Peripheral parenteral nutrition feeding into small veins in the arm.
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26. Total Parenteral Nutrition (p. 460)
Catheter placement for TPN: direct line by subclavian vein to superior vena cava.
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27. Total Parenteral Nutrition (cont’d) (p. 460)
Catheter placement for TPN: Peripherally inserted central catheter line.
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28. Total Parenteral Nutrition (cont’d) (p. 460)
Catheter placement for TPN: Tunneled catheter.
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29. Lesson 22.2: Nutrition Support Related to GI Surgery
Nutrition problems related to GI surgery require diet modifications because of the surgery’s effect on normal food passage.
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30. Special Nutrition Needs after Gastrointestinal Surgery (p. 460)
Gastrointestinal surgery requires special nutrition attention
Nutrition therapy varies depending on the surgery site
Sites of gastrointestinal surgery include the mouth, throat and neck, stomach, gallbladder, intestines, or rectum.
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31. Mouth, Throat, and Neck Surgery (p. 462)
Requires modification in the mode of eating
Patients cannot chew or swallow normally
Oral liquid feedings ensure adequate nutrition
Mechanical soft diet may be optimal
Enteral feedings required for radical neck or facial surgery
Review side effects and nursing care for tube feedings.
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32. Gastric Surgery (p. 462)
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 relation to the entire gastrointestinal system.
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33. Gastrectomy (p. 462)
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 by 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.
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34. Dumping Syndrome (p. 462)
Common 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
Define higher osmolality and describe its implications.
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35. Case Study
Mary Ann has undergone bariatric surgery for extreme obesity. She is 35 years of age. Her surgery went well.
Case Study:
Mary Ann has undergone bariatric surgery for extreme obesity. She is 35 years of age. Her surgery went well.
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36. Case Study (cont’d)
Name two factors that can reduce nutrient availability.
The combination of severely reduced intake coupled with dumping syndrome can dramatically reduce nutrient availability.
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37. Case Study (cont’d)
Outline the progression of Mary Ann’s nutrition plan postsurgery.
Postsurgery after gastric bypass, patients progress slowly from a clear liquid diet to a regular diet at approximately 6 weeks postsurgery, but are limited to approximately 1 cup of food per meal from that point forward. Should avoid using a straw to reduce air swallowing.
Review Table Diet Stages after Bariatric Surgery
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38. Bariatric Surgery (p. 463)
Typical deficiencies in several micronutrients
Progress from clear liquid to regular diet over about 6 weeks
Thereafter limited to about 1 cup of food
Subject to dumping syndrome
Patients can avoid most of the distressing symptoms if they carefully adhere to the postoperative diet.
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39. Gallbladder Surgery (p. 463)
Cholecystectomy is 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
After surgery, the hormonal stimulation for bile secretion still functions in the surgical area, causing pain with high intake of fats.
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40. Gallbladder Surgery (cont’d) (p. 465)
Gallbladder with stone (cholelithiasis).
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41. Intestinal Surgery (p. 464)
Intestinal resections are required in cases involving tumors, lesions, or obstructions
When most of the small intestine is removed, total parenteral nutrition is used with small allowance of oral feeding
Stoma may be created for elimination of fecal waste (ileostomy, colostomy)
In less-severe cases, a low-fiber diet may be used briefly.
The goal is to advance to a regular diet.
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42. Intestinal Surgery (cont’d) (p. 466)
Ileostomy.
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43. Intestinal Surgery (cont’d) (p. 466)
Colostomy.
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44. Rectal Surgery (p. 466)
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.
Describe items included in a clear liquid diet.
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45. Special Nutrition Needs for Patients with Burns (p. 466)
Tremendous nutritional challenge
Plan of care influenced by:
Age
Health condition
Burn severity
Plan constantly adjusted
Critical attention paid to amino acid needs
Why are amino acid needs so important at each stage? (For tissue rebuilding, fluid-electrolyte balance, energy (kilocalorie) support)
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46. Special Nutrition Needs for Patients with Burns (cont’d) (p. 466)
Type and extent of burns.
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47. Stages of Nutrition Care of Burn Patients (p. 466)
Burn shock or ebb phase
Massive edema at burn site
Loss of heat, water, electrolytes, protein
Immediate IV fluid therapy with salt solution or lactated Ringer’s solution
After 12 hours, albumin solutions or plasma
MNT not a priority at this time
Stability and resuscitation of the patient are more important than nutrition at this stage.
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48. Stages of Nutrition Care of Burn Patients (p. 467)
Acute or flow phase
Sudden diuresis indicates initial therapy success
Constant attention to fluid intake and output
Around the end of first week, bowel function returns and rigorous MNT begins
Increased nutrient and energy needs have three causes:
Tissue destruction, which means large losses of protein and electrolytes that must be replaced
Tissue catabolism, with further loss of lean body mass and nitrogen
Increased metabolism boosts nutrition needs
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49. Medical Nutrition Therapy (p. 467)
High protein intake
High energy intake
Caloric needs based on total BSA burned
Liberal portion of kilocalories from carbohydrates
Avoid overfeeding
High vitamin and mineral intake
Which vitamins and minerals are needed? (Vitamins A and C, zinc, thiamin, riboflavin, niacin)
Pay close attention to electrolytes and calcium/phosphorus ratios.
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50. Stages of Nutrition Care of Burn Patients (p. 468)
Dietary management
Careful intake record
Oral feedings preferred
Enteral or parenteral route may be used if oral intake deficient
Follow-up reconstruction
Nutrition support for skin grafting, reconstructive surgery
Personal support to rebuild will and spirit
Initiating nutrition support soon after the burn injury may stimulate protein retention and reduce the hypermetabolic response.
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51. Williams' Basic Nutrition & Diet Therapy
14th Edition
Chapter 14
Food Habits and Cultural Patterns
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52. Lesson 14.1: Social, Cultural, and Economic Patterns and Food Habits
Personal food habits develop as part of a person’s social and cultural heritage as well as individual lifestyle and environment.
Social and economic change often results in alterations in food patterns.
American eating patterns are influenced by many different cultures.
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53. Social, Psychological, and Economic Influences on Food Habits (p. 264)
Social structure
Groups may be formed by economic status, education, residence, occupation, family
Group affiliation influences food attitudes and choices
Food and social factors
Food symbolizes acceptance and warmth in social relationships
Certain foods trigger childhood memories
Discuss how social structure, religion, education, and social status influence food habits.
People accept food advice from family, friends, or trusted authorities.
Does your culture have any food taboos?
What are your culture’s table manners?
Food and gender (who purchases, prepares, distributes food in the family?)
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54. Psychologic Influences (p. 265)
Diet patterns
Food has many personal meanings
Many psychologic factors rooted in childhood
Food and psychosocial development
Food relates closely to psychosocial development
Toddlers may become “picky eaters” to control parents
Food neophobia (fear of unfamiliar foods) is normal developmental factor
Discuss comfort foods. What kinds of foods are more likely to be comfort foods?
Certain foods stimulate endorphins.
The ambivalent relationship with food—wanting to enjoy it, but being conscious of weight gain—is a struggle experienced by many.
Attempts to restrict intake of certain foods can increase the desire for these particular foods, leading to food cravings.
Women more commonly report food cravings than men do. Depressed mood appears to influence the severity of these cravings.
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55. Marketing and Environmental Influences (p. 265)
Media
Peers
Convenience items
Grocery stores
Cartoon characters
Ask students how these factors influence food choices.
How have students been influenced to purchase specific products in grocery stores?
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56. Family Income (p. 265) Low-income families suffer extreme need
Illness, hunger, and malnutrition are more common in this group
About 14.3% of Americans live below poverty level
Cost and accessibility, education, and knowledge are the socioeconomic influences on food choices.
Low-income groups have a greater tendency to consume unbalanced diets. In particular, low-income groups have low intakes of fruits and vegetables.
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57. Cultural Development of Food Habits (p. 265)
Food habits grow from many influences
Personal
Cultural
Social
Economic
Psychological
Discuss how students form their existing eating patterns and food habits.
Discuss how each of these influences affects individual food choices and habits.
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58. Cultural Development of Food Habits (cont’d) (p. 266)
Food habits are learned through everyday living and family relationships
Food habits are primarily based on food availability, economics, personal food beliefs
Cultural background and customs largely determine what is eaten
Foods may take on symbolic meaning
Examine the situations in which a person is most likely to overeat or make certain food choices.
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59. Case Study
List three ways your own culture has helped share your personal food experiences. Share with the group if desired.
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60. Traditional Cultural Food Patterns (p. 266)
Shift in focus from “melting pot” to “diversity”
American cities retain pockets of ethnic groups
Cultural food habits are retained
Discuss the ethnic groups that have a visible presence in your city or town.
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61. Religious Dietary Laws (p. 266)
Christianity
Catholic
Protestant
Eastern Orthodox
Judaism
Hinduism
Buddhism
Islam
Each follower interprets these dietary practices in his or her own way.
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62. Jewish (p. 266)
Different dietary laws depending on orthodox, conservative, or reform beliefs
Dietary laws are called Rules of Kashruth; foods prepared according to these laws are kosher
Meat should come only from animals that chew their cud and have cloven hooves; no pork or birds of prey
Meat and milk products are not mixed
Shellfish and crustaceans are avoided
No eggs with blood spots are eaten
Discuss the origins of the dietary laws.
Where can one obtain kosher food in your community?
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63. Influence of Festivals (Jewish) (p. 266)
Many traditional Jewish foods relate to festivals of the Jewish calendar
Examples: bagels, blintzes, borscht, challah, gefilte fish, kasha, knishes, lox, matzo, strudel
What are some Jewish holidays that involve food?
Have the students heard of any of these foods before? Which have been adapted to American cuisine?
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64. Muslim (p. 267)
Dietary laws depend on restriction or prohibition of some foods, promotion of other foods
Milk products: permitted at all times
Fruits and vegetables: permitted unless fermented
Breads and cereals: permitted unless contaminated
Seafood and land animals: permitted
Pork and alcohol: prohibited
Discuss the origins of the Islamic food laws.
Consider how hard it would be for a person in America to follow Jewish or Islamic dietary laws.
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65. Representative Foods (Muslim) (p. 267)
Bulgur
Falafel
Fatayeh
Kibbeh
Pilaf
Pita
Tabouli
Ask students which of these have been adapted to American cuisine. Which ones have they eaten in the last few months?
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66. Influence of Festivals (Muslim) (p. 268)
Ramadan
30-day period of daylight fasting
Nights often spent in special feasts
All Muslims, regardless of condition, observe this fasting
Some patients (e.g., pregnant or breast-feeding) may have complications
Explain the fasting during Ramadan and how this affects food choices and health.
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67. Case Study Mr. H practices Muslim dietary laws.
Discuss these laws in regard to a meal consisting of pork medallions, milk, fresh salad with lettuce and tomato and cucumber, steamed carrots and pilaf.
Case Study:
Muslim food pattern consists of the following:
Milk products—permitted at all times
Breads and cereals—permitted unless contaminated or unharmful
Meats—seafood and land animals are permitted; pork is strictly prohibited. Typically eat kosher meats, because animal is not to be eaten.
Alcohol is strictly prohibited.
Pork is strictly prohibited in this meal.
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68. Spanish Influences (p. 268)
Mexican
Basic foods are dried beans, chili peppers, corn
Small amounts of meat and eggs are used
Fruit consumption depends on availability and price
Puerto Rican
Food pattern is similar to Mexican
Tropical fruits and vegetables are added
Basic foods include viandas (starchy vegetables and fruits), rice, beans
Discuss the advantages and disadvantages of the Americanization of native diets.
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69. National Food Guides for Mexico and Puerto Rico (p. 269)
In the Puerto Rican diet, milk, meat, yellow and green vegetables, and other fruits are used in limited quantities.
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70. Native American (p. 268) Indian and Alaska Natives Many diverse groups
All have a spiritual devotion to the land
Food has great religious and social significance
Food differs according to what can be grown locally, harvested or hunted on the land, or fished from local waters
Discuss changes in the Native American diet, including the addition of alcohol, high-fat foods, and high-sodium foods.
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71. Native American (cont’d) (p. 270)
Native American: Southern Arizona American Indian Food Guide: Choices for a Healthy Life
Ask students to identify some of the health benefits and health hazards of the American Indian food habits.
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72. Influences of Southern United States (p. 270)
African Americans
Food patterns developed through creative ability to turn basic staples into memorable food
Traditional breads include hot breads (biscuits, spoonbread, cornbread)
Wide variety of vegetables and leafy greens (turnip, collard, mustard) are used
Pork is a common meat
The popular term for African-American cooking is soul food.
Eggs and some cheese are used
Little milk is used (except for baking)
Many of these foods are rich in nutrients, as found in collard greens and other leafy green and yellow vegetables, legumes, beans, rice, and potatoes. Other parts of the diet, however, are low in fiber, calcium, and potassium, and high in fat.
Common ways for African Americans to prepare food include frying, barbecuing, and serving foods with gravy and sauces. Home-baked cakes and pies are also common.
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73. French Americans (p. 272)
Cajuns in southern Louisiana are descendants of the French colonists of Arcadia (now Nova Scotia)
French culinary background blended with Creole cooking around New Orleans
Foods are strongly flavored, spicy
Seafood is abundant
Typical dishes include seafood or chicken gumbo, jambalaya, red beans and rice, blackened fish.
Discuss advantages and disadvantages of Cajun cuisine.
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74. Asian Food Patterns (p. 273)
Chinese
Use a wok for quick stir-frying with little fat
Vegetables and rice are staples
Meat, eggs, and tofu are sources of protein
Japanese
Rice is basic grain
Many varieties of fish and shellfish used
Vegetables usually steamed
Diet is high in sodium, low in milk
Most Asians living in America adhere to a traditional Asian diet interspersed with American foods, particularly breads and cereals.
Dairy products are not consumed in sufficient quantity, except for ice cream. Calcium is consumed through tofu and small fish.
Asian food preparation techniques include stir-frying, barbecuing, deep-frying, boiling, and steaming. All ingredients are carefully prepared (chopped, sliced, etc.) before starting the cooking process.
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75. Southeast Asian (p. 273)
Southeast Asian: Vietnamese, Indonesian, Cambodian, Laotian
Rice is a staple
Soups are common
Fish, shellfish, pork, chicken, and duck are common
Red meat eaten only once or twice a month
Nuts and legumes are the primary sources of protein.
Stir-frying in a wok with a small amount of lard or peanut oil is a common method of cooking.
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76. National Food Guides for China, Japan, and Korea (p. 274)
Ask students to compare the food guides of China, Japan, and Korea. How are they similar, and how do they differ?
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77. Mediterranean Influences (p. 274)
Italian
Bread and pasta are basic ingredients
Cheese, meats, poultry, fish, sausages, cold cuts, and vegetables commonly used
Olive oil, garlic, herbs, and wine used in cooking
Greek
Bread is the center of every meal
Cheese, yogurt, vegetables, rice, lamb, and fish commonly used
Mediterranean countries are known for leisurely dining. Eating more slowly, enjoying company, and mentally relaxing can all benefit health.
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78. Mediterranean Influences (cont’d) (p. 275)
Discuss the benefits of the Mediterranean diet; why is it considered heart healthy?
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79. Changes in American Food Habits (p. 275)
Basic determinants
Physical
Social
Psychological
Factors influencing change
Income
Technology
Environment
Access to food
Vision
Vision influences change through the media. Marketing strongly influences children’s food preferences and requests.
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80. Changes in American Food Habits (cont’d) (p. 276)
Changing American food patterns
Household dynamics
Family meals
Pattern of “grazing,” growing portion sizes
Fast foods
Health and fitness
Economical buying
Do you eat more meals or snacks?
Do you sit down with others at a table when you eat?
Fast food restaurants are becoming a norm for dining in America. What are some healthier food options that can be ordered?
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