Chapter 022

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


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


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


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


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 reserves Reason 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 diminished

Protein losses occur during surgery from tissue breakdown and blood loss

Catabolism usually occurs after surgery (tissue breakdown and loss exceed tissue buildup)


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


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


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


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


Minerals (p. 451)

Potassium Phosphorus Sodium, chloride Iron 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


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


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


Methods of Feeding (p. 456)


Alternative Routes (p. 455)

Esophagostomy Percutaneous endoscopic gastrostomy Percutaneous endoscopic jejunostomy


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


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


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 (cont’d)

Evaluate appropriateness of recommended feeding route.

What evaluation criteria should be considered or what additional questions should be asked?



Is parenteral nutrition more appropriate for Mrs. White? Why or why not?


Peripheral Parenteral Feeding(p. 459)


Total Parenteral Nutrition (p. 460)


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


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


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.


Special Nutrition Needs after Gastrointestinal Surgery (p. 460)

Gastrointestinal surgery requires special nutrition attention

Nutrition therapy varies depending on the surgery site


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


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 common Patient may be fed by jejunostomy Frequent small, simple oral feedings are resumed

according to patient’s tolerance


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


Case Study

Mary Ann has undergone bariatric surgery for extreme obesity. She is 35 years of age. Her surgery went well.



Name two factors that can reduce nutrient availability.



Outline the progression of Mary Ann’s nutrition plan postsurgery.


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


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


Gallbladder Surgery (cont’d)(p. 465)


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)


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 challenge Plan of care influenced by:

Age Health condition Burn severity

Plan constantly adjusted Critical attention paid to amino acid needs


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 After 12 hours, albumin solutions or plasma MNT not a priority at this time



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 intake High energy intake

Caloric needs based on total BSA burned Liberal portion of kilocalories from carbohydrates Avoid overfeeding

High vitamin and mineral intake



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


Health & Medicine

Chapter 022