1. Williams' Basic Nutrition & Diet Therapy
14th Edition
Chapter 22
Surgery and Nutrition Support
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2. 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
*controlling edema: when serum protein levels are low, osmotic pressure is lost and edema develops
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
Water loss may occur through vomiting, hemorrhage, fever, infection or diuresis**
Loose sodium and chloride**
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
CHO’s spare protein for tissue building and help to avoid liver damage by maintaining glycogen reserves in the liver tissue**
Energy needs increased for extensive surgery or burn patients
Carbohydrates also help prevent liver damage by maintaining glycogen reserves in the liver tissue. 12
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13. Vitamins (p. 451) Vitamin C to build connective tissue**
Sources**
B vitamins to metabolize protein and energy
B-complex vitamins to build hemoglobin
Vitamin K to promote blood clotting
**patients treated with antibiotics may have a decreased gut flora and vitamin K synthesis
These vitamins are important in wound healing.
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14. Minerals (p. 451)
*Tissue catabolism results in cell potassium and phosphorous loss
Potassium
Phosphorus
Sodium, chloride
Iron
*iron deficiency anemia may develop from blood loss or inadequate iron absorption*
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
*risk for hyperglycemia
*table 22-2
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. Criteria for selecting a nutrition support method
*Enteral
*parenteral
BOX 22-1
ASSISTED feeding guidelines
*Blind client
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19. Methods of Feeding (p. 456) Types of enteral feeding.
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20. 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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21. 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
*pureed table food for tube feeding may present these problems
Safety**
Adding fiber-rich formulas may improve bowel function and help reduce diarrhea.
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22. 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**
TPN provides crucial nutrition support from solutions that contain glucose, amino acids, electrolytes*
Must be discussed with patient and/or family first
*complications of TPN: metabolic, rebound hypoglycemia, hyperglycemia and infections, phlebitis
*start infusion slowly
These methods are used when the patient cannot tolerate food or formula through the GI tract.
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23. Propofol and lipids in nutrition support
Lipid emulsion contributes 1.1 kcal per ml, enteral or parenteral nutrition solutions must provide reduced calories from fat to compensate for those that are provided with propofol
*energy metabolism generates CO2 production
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24. Peripheral Parenteral Feeding (p. 459)
Peripheral parenteral nutrition feeding into small veins in the arm.
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25. Total Parenteral Nutrition (p. 460)
Catheter placement for TPN: direct line by subclavian vein to superior vena cava.
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26. Total Parenteral Nutrition (cont’d) (p. 460)
Catheter placement for TPN: Peripherally inserted central catheter line.
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27. Total Parenteral Nutrition (cont’d) (p. 460)
Catheter placement for TPN: Tunneled catheter.
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28. 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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29. 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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30. 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 when the client is debilitated, tube feedings may be indicated*
Review side effects and nursing care for tube feedings.
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31. 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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32. 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*
*small, bland meals, low in bulk
Possible results of vagotomy: stomach empties poorly, allowing food to ferment; this can lead to gas and diarrhea.
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33. 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 terminates the event
Occurs 30 to 60 minutes after meal when readily soluble CHO’s enter or dump into the small intestine
Ex: cookies, if simple CHO’s were eaten, late dumping ~2 hours after eating would occur*
When water is drawn from the circulatory system into the intestine, shift in water rapidly shrinks the vascular fluid volume, causing shock*
Define higher osmolality and describe its implications.
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34. 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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35. 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
*function is to concentrate and store bile which helps with the absorption and digestion of fat*
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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36. Gallbladder Surgery (cont’d) (p. 465)
Gallbladder with stone (cholelithiasis).
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37. 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)*
Ileostomy-food may be fairly liquid in the GI tract and more problems are encountered with management*
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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38. Intestinal Surgery (cont’d) (p. 466)
Ileostomy.
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39. Intestinal Surgery (cont’d) (p. 466)
Colostomy.
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40. 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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41. Special Nutrition Needs for Patients with Burns (p. 466)
Tremendous nutritional challenge
Plan of care influenced by:
Age
Health condition
Burn severity**
*superficial, second degree, third degree
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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42. Special Nutrition Needs for Patients with Burns (cont’d) (p. 466)
Type and extent of burns.
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43. 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 **
**replaces water and electrolytes and prevent shock
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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44. 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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45. 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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46. 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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