Williams' Basic Nutrition & Diet Therapy Chapter 22 Surgery and Nutrition Support Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights

Williams' Basic Nutrition & Diet Therapy

Chapter 22Surgery and Nutrition Support

Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 1

14th Edition

Nutrition Support and Methods of FeedingSurgical 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.


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


Nutrition Needs of General Surgery Patients (p. 447)Nutrition needs are greatly

increased in patients undergoing surgery

Deficiencies easily developPay careful attention to:

◦Nutritional status before surgery◦Individual nutrition needs after

surgery


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, costCopyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 5

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 storesVitamin and mineral deficiencies

should be correctedWater balance should be

assessed


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


Emergency Surgery (p. 449)No time for building up ideal nutrient

reservesReason for maintaining good nutrition

status at all times


Postoperative Nutrition Care: Nutrient Needs for Healing (p. 449)Postoperative nutrient losses are great

but food intake is diminishedProtein 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)


Need for Increased Protein(p. 450)Building tissue for wound healingControlling edemaControlling shock by maintaining blood

volumeHealing bone: protein is essentialResisting infection: protein tissues are major

components of immune systemTransporting lipids: fat is important

component of tissue structure


Water (p. 451)To prevent dehydrationWater loss may occur through

vomiting, hemorrhage, fever, infection or diuresis**

Loose sodium and chloride**Elderly require special attentionLarge water losses possible from

various routesIV fluidsOral fluids as soon as possible


Energy (p. 451)Provide sufficient nonprotein kilocalories for

energy to spare protein for tissue buildingCHO’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

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12

Vitamins (p. 451)Vitamin C to build connective tissue**

◦ Sources**B vitamins to metabolize protein and energyB-complex vitamins to build hemoglobinVitamin K to promote blood clotting**patients treated with antibiotics may have

a decreased gut flora and vitamin K synthesis


Minerals (p. 451)*Tissue catabolism results in cell potassium

and phosphorous lossPotassiumPhosphorusSodium, chloride Iron

◦ *iron deficiency anemia may develop from blood loss or inadequate iron absorption*

Zinc


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


Methods of Feeding: Oral(p. 452)Allows more needed nutrients to be addedStimulates normal action of the

gastrointestinal tractEarly feedings associated with reduced

complicationsProgresses from clear to full liquids, then to a

soft or regular dietRoutine house dietAssisted oral feeding: try to avoid making

patient feel inadequate


Methods of Feeding: Enteral(p. 454)Used when oral feeding cannot be toleratedNasogastric tube is most common route**Nasoduodenal or nasojejunal tube more

appropriate for patients at risk for aspiration, reflux, or continuous vomiting


Criteria for selecting a nutrition support method*Enteral*parenteralBOX 22-1

ASSISTED feeding guidelines*Blind client

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Methods of Feeding (p. 456)


Alternative Routes (p. 455)EsophagostomyPercutaneous endoscopic gastrostomyPercutaneous endoscopic jejunostomy


Alternative Route Formulas(p. 456)Generally prescribed by the physician Important to regulate amount and rate of

administrationWide variety of commercial formulas

available Rate: bolus or continuousMonitoring for complications: diarrhea is

most common complication*pureed table food for tube feeding may

present these problems◦ Safety**


Parenteral Feedings (p. 458)**Definition: any method other than the

normal GI routePeripheral parenteral nutrition: less than 5 to

7 daysTotal 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


Propofol and lipids in nutrition supportLipid 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

Copyright © 2013, 2009, 2005 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Peripheral Parenteral Feeding(p. 459)


Total Parenteral Nutrition (p. 460)


Total Parenteral Nutrition (cont’d) (p. 460)


Total Parenteral Nutrition (cont’d) (p. 460)


Nutrition Support Related to GI SurgeryNutrition problems related to GI surgery

require diet modifications because of the surgery’s effect on normal food passage.


Special Nutrition Needs after Gastrointestinal Surgery (p. 460)Gastrointestinal surgery requires special

nutrition attentionNutrition therapy varies depending on the

surgery site


Mouth, Throat, and Neck Surgery (p. 462)Requires modification in the mode of eatingPatients cannot chew or swallow normallyOral liquid feedings ensure adequate

nutritionMechanical soft diet may be optimal*Enteral feedings required for radical neck or

facial surgery when the client is debilitated, tube feedings may be indicated*


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


Gastrectomy (p. 462) Increased gastric fullness and distention may

result if gastric resection involved a vagotomy (cutting of the vagus nerve)

Weight loss is commonPatient may be fed by jejunostomy*Frequent small, simple oral feedings are

resumed according to patient’s tolerance*◦ *small, bland meals, low in bulk


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* Copyright © 2013 Mosby, Inc., an imprint

of Elsevier Inc. All rights reserved. 33

Bariatric Surgery (p. 463)Typical deficiencies in several micronutrientsProgress from clear liquid to regular diet over

about 6 weeksThereafter limited to about 1 cup of foodSubject to dumping syndrome


Gallbladder Surgery (p. 463)*Cholecystectomy is removal of the

gallbladderSurgery is minimally invasiveSome moderation in dietary fat is usually

indicated after surgeryDepending 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*


Gallbladder Surgery (cont’d)(p. 465)


Intestinal Surgery (p. 464) Intestinal resections are required in cases

involving tumors, lesions, or obstructionsWhen 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*


Intestinal Surgery (cont’d)(p. 466)


Intestinal Surgery (cont’d)(p. 466)


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.


Special Nutrition Needs for Patients with Burns (p. 466)Tremendous nutritional challengePlan of care influenced by:

◦Age◦Health condition◦Burn severity**

*superficial, second degree, third degree

Plan constantly adjustedCritical attention paid to amino

acid needsCopyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 41

Special Nutrition Needs for Patients with Burns (cont’d) (p. 466)


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 Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 43

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


Medical Nutrition Therapy(p. 467)High protein intakeHigh energy intake

◦Caloric needs based on total BSA burned

◦Liberal portion of kilocalories from carbohydrates

◦Avoid overfeedingHigh vitamin and mineral intake


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 deficientFollow-up reconstruction

◦Nutrition support for skin grafting, reconstructive surgery

◦Personal support to rebuild will and spirit


Documents

Williams' Basic Nutrition & Diet Therapy Chapter 22 Surgery and Nutrition Support Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights