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  • Malnutrition hinders healing.
  • Proper nutrition after surgery is essential for wound healing and recovery.
  • Ask students to explain how an impaired immune system, impaired wound healing, and an increased risk of infection are related.
  • 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.
  • 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)
  • Following a healthy diet at all times ensures that one will have the nutrient status needed for urgent surgery.
  • Protein also may be lost through various body fluids or exudates.
  • 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)
  • Surgery disrupts fluid distribution in the patient, which can reduce circulation and hinder recovery.
  • Carbohydrates also help prevent liver damage by maintaining glycogen reserves in the liver tissue.
  • These vitamins are important in wound healing.
  • Zinc is particularly important in wound healing, and even patients consuming normally adequate amounts of zinc through the diet may benefit from zinc supplementation.
  • Oral feedings are the method of choice when they can be tolerated.
  • What does “NPO” mean? (Nothing by mouth)Individual tolerance and needs serve as the guide.Frequent small meals may be advised.
  • Modern small-bore feeding tubes are relatively comfortable for patients.
  • Types of enteral feeding.
  • The nasoenteric route is used for short-term feedings, but these alternative routes are more comfortable for long-term feeding.
  • Adding fiber-rich formulas may improve bowel function and help reduce diarrhea.
  • These methods are used when the patient cannot tolerate food or formula through the GI tract.
  • 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.
  • 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.
  • 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.
  • Peripheral parenteral nutrition feeding into small veins in the arm.
  • Catheter placement for TPN: direct line by subclavian vein to superior vena cava.
  • Catheter placement for TPN: Peripherally inserted central catheter line.
  • Catheter placement for TPN: Tunneled catheter.
  • Sites of gastrointestinal surgery include the mouth, throat and neck, stomach, gallbladder, intestines, or rectum.
  • Review side effects and nursing care for tube feedings.
  • Describe causes for stomach surgery and its incidence.Review the anatomy and physiology of the stomach in relation to the entire gastrointestinal system.
  • Possible results of vagotomy: stomach empties poorly, allowing food to ferment; this can lead to gas and diarrhea.
  • Define higher osmolality and describe its implications.
  • Case Study:Mary Ann has undergone bariatric surgery for extreme obesity. She is 35years of age. Her surgery went well.
  • The combination of severely reduced intake coupled with dumping syndrome can dramatically reduce nutrient availability.
  • 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 22-6 - Diet Stages after Bariatric Surgery
  • Patients can avoid most of the distressing symptoms if they carefully adhere to the postoperative diet.
  • After surgery, the hormonal stimulation for bile secretion still functions in the surgical area, causing pain with high intake of fats.
  • Gallbladder with stone (cholelithiasis).
  • In less-severe cases, a low-fiber diet may be used briefly.The goal is to advance to a regular diet.
  • Ileostomy.
  • Colostomy.
  • Describe items included in a clear liquid diet.
  • Why are amino acid needs so important at each stage? (For tissue rebuilding, fluid-electrolyte balance, energy (kilocalorie) support)
  • Type and extent of burns.
  • Stability and resuscitation of the patient are more important than nutrition at this stage.
  • Increased nutrient and energy needs have three causes: Tissue destruction, which means large losses of protein and electrolytes that must be replacedTissue catabolism, with further loss of lean body mass and nitrogenIncreased metabolism boosts nutrition needs
  • Which vitamins and minerals are needed? (Vitamins A and C, zinc, thiamin, riboflavin, niacin)Pay close attention to electrolytes and calcium/phosphorus ratios.
  • Initiating nutrition support soon after the burn injury may stimulate protein retention and reduce the hypermetabolic response.

Chapter 022 Chapter 022 Presentation Transcript

  • Williams' Basic Nutrition & Diet Therapy Chapter 22 Surgery and Nutrition Support Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 1 14th Edition
  • 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. 2Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 3Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 4Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 5Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 6Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 7Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Emergency Surgery (p. 449)  No time for building up ideal nutrient reserves  Reason for maintaining good nutrition status at all times 8Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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) 9Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 10Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 11Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 12Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 13Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Minerals (p. 451)  Potassium  Phosphorus  Sodium, chloride  Iron  Zinc 14Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 15Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 16Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 17Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Methods of Feeding (p. 456) 18Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Alternative Routes (p. 455)  Esophagostomy  Percutaneous endoscopic gastrostomy  Percutaneous endoscopic jejunostomy 19Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 20Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 21Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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. 22Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Case Study (cont’d)  Evaluate appropriateness of recommended feeding route.  What evaluation criteria should be considered or what additional questions should be asked? 23Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Case Study (cont’d)  Is parenteral nutrition more appropriate for Mrs. White? Why or why not? 24Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Peripheral Parenteral Feeding (p. 459) 25Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Total Parenteral Nutrition (p. 460) 26Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Total Parenteral Nutrition (cont’d) (p. 460) 27Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Total Parenteral Nutrition (cont’d) (p. 460) 28Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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. 29Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Special Nutrition Needs after Gastrointestinal Surgery (p. 460)  Gastrointestinal surgery requires special nutrition attention  Nutrition therapy varies depending on the surgery site 30Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 31Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 32Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 33Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 34Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Case Study  Mary Ann has undergone bariatric surgery for extreme obesity. She is 35 years of age. Her surgery went well. 35Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Case Study (cont’d)  Name two factors that can reduce nutrient availability. 36Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Case Study (cont’d)  Outline the progression of Mary Ann’s nutrition plan postsurgery. 37Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 38Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 39Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Gallbladder Surgery (cont’d) (p. 465) 40Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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) 41Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Intestinal Surgery (cont’d) (p. 466) 42Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Intestinal Surgery (cont’d) (p. 466) 43Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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. 44Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 45Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • Special Nutrition Needs for Patients with Burns (cont’d) (p. 466) 46Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 47Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 48Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 49Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
  • 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 50Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.