Surgical Conditions.pdf

Surgical Conditions Cheshire J. Que, RN, RND-RDN  Metabolic Changes Cessation of peristalsis Rapid protein catabolism Increased blood glucose Increased utilization of adipose tissues Sodium retention Dehydration Calcium loss Increased Vitamin C utili...

Surgical Conditions Cheshire J. Que, RN, RND-RDN  Metabolic Changes Cessation of peristalsis Rapid protein catabolism Increased blood glucose Increased utilization of adipose tissues Sodium retention Dehydration Calcium loss Increased Vitamin C utilization Anorexia Anemia  Dietary Management (Pre-Operative) Emergency Operation Elective Surgery NPO for 8 hours High calorie (Underweight) Parenteral – whole blood or plasma (poor High carbohydrates nutritional status) + 5% glucose in water, Saline solution, High protein vitamins and potassium Increase vitamins, C, K and B complex Increase minerals, phosphorus, potassium, sodium, chloride and iron Increase fluids Dietary Management (Post-Operative) Fluid and electrolyte balance Adequate protein and calorie intake Adequate total nutrient intake (wound healing and resumption of activities) Dietary Management (Post-Operative) Minor Surgery Major Surgery Liquids NPO 24-48 hours, prevent aspiration Normal diet (check for GIT activity) Nutrition support, IV amino acid solution, TPN, Tube feeding Oral diet, liquid to full as tolerated Specific Surgical Conditions  Surgery of the Mouth, Throat, and Esophagus Tooth extraction – Fluid to soft to full diet as tolerated Tonsillectomy – very cold, mild flavored food. Avoid fibrous food. Warm fluids on 2nd day. Progress to normal diet after 1 week Mouth – Full liquid/pureed food; Tube feeding Provide food with minimal chewing  Gastrectomy Malignancy Refractory peptic ulcer disease Abscess Sepsis Gastrointestinal bleeding  Gastrectomy Weight loss Impaired protein digestion (decreased pepsin and HCL) Impaired fat utilization (decreased biliary and pancreatic secretion) Increased intestinal motility Iron is not absorbed efficiently (hypochromic microcytic anemia) Macrocytic anemia, Vitamin B12 deficiency  Procedures and Resections Vagotomy – decreased acid production and response to gastrin Pyloroplasty – Gastric emptying is affected Billroth I – partial gastrectomy, anastomosis of proximal end of jejunum to distal end of stomach Roux-en-Y – partial gastrectomy, anastomosis of the jejunum to the upper portion of the stomach, small pouch created  Gastrectomy Nutrition Therapy Immediate post-operative period Later period  Immediate Post-Operative Schedule Feeding 24 to 48 hours NPO, IV Day 2 to 4 Iced water with IV Day 5 1-2 oz WATER every EVEN hour 1-2 oz. MILK every ODD hour Day 6 Soft, low fiber food Day 7 Tender protein sources, pureed vegetables - 5 to 6 meals a day - High protein and high fat - Low carbohydrate and simple sugar - Moderate temperature  Dumping Syndrome Response to undigested food in the jejunum Increased osmolar load enters the small intestine quickly Decrease plasma volume Intestinal distension Hypoglycemia  Dumping Syndrome Palpitation Feeling warmth Exhaustion Dizziness and weakness Faintness Tachycardia Sweating Hunger Nausea Tremors Cramping, fullness Abdominal pain Diarrhea (10 to 20 mins after eating)  Types of Dumping Syndrome Type Onset Early dumping syndrome 10 to 20 minutes after eating Intermediate dumping syndrome 20 to 30 minutes after eating Late dumping syndrome 1 to 3 hours after eating  Nutrition Therapy Modifications Rationale Small frequent feedings (5 to 6), supine To prevent dumping of food into the position intestines High protein Hydrolyzed slowly, rebuilds tissue and strength High fat Delay passage of food, meet energy needs High calories Strength Simple CHO, avoid Increase dumping of food in jejunum Dry solid diet Slowly enter jejunum Low fiber, low residue diet Prevent rapid dumping of food Avoid alcohol or sweet carbonated Prevent dumping syndrome beverages  Intestinal Surgery Changes in absorption, motility and production of waste products Considerations: location of stoma and resection Ileostomy Colostomy Jejunoileostomy  Ileostomy Removal of entire colon, rectum and anus Watery, less-formed stool Initial output 1,200ml per day 600 ml output per day 90 mmol/L sodium loss (stoma in duodenojejunal flexure) 140 mmol/L sodium loss (stoma in terminal ileum)  Ileostomy Vitamin B12 deficiency Fat soluble vitamin deficiency Monitor Vitamin D Ensure adequate absorption Alleviate odor, gas and diarrhea Optimize nutritional status post op  Colostomy Removal of rectum and anus Water absorption ability is retained Semi-formed stool Monitor Vitamin K and B Vitamins Alleviate constipation and diarrhea Optimize nutrition status post op  Colostomy Low fiber Avoid beer, garlic, leeks, Progress to whole onions, egg, corn, grains cruciferous vegetables, Avoid gas forming food dried beans and peas, fish, grapes, dairy, Avoid prune juice peanuts, unpeeled Avoid Carbonated apple, nuts/seeds, drinks popcorn Avoid Fried food Avoid spicy food Avoid refined sugars  Colostomy Avoid chewing gums Avoid using straw Avoid eating too fast Avoid skipping meals Avoid smoking Keep hydrated Observe regular meals  High Oxalate Foods Beans Coffee Beer Nuts Beet Sweet Potatoes Carob Tofu Chocolate Cocoa Dark leafy vegetables Instant tea  Jejunoileostomy 90% of small bowel is bypassed Weight loss Reduced absorption of nutrients  Cholecystectomy Removal of gallbladder Low fat for several weeks or months - steatorrhea High protein  Peritonitis and Intestinal Obstruction NPO 24 to 48 hours, IV Clear liquids to low residue Transition to full diet as tolerated  Rectal Surgery (Hemorrhoidectomy) Removal of external or internal hemorrhoids Pain on elimination Bowel movement is delayed/discouraged NPO 24 to 48 hours Clear liquid Low fiber-low residue Can give strained fruit juices  Fractures and Mechanical Trauma Increased protein breakdown Loss of potassium, phosphorus and sulphur Development of osteoporosis, calcium loss Caution: development of renal calculi Fluid and electrolyte loss  Fractures and Mechanical Trauma High calories High protein Increased electrolytes and fluids Calcium from natural sources (dark, leafy greens, dairy)  Burns First degree – not serious, patient can go home after first aid treatment Second degree – Body surface affected: 14% adults, 10% for children Third degree – full thickness skin loss including fat layer Full thickness injury – grafting required Partial thickness injury – epithelium remains  Burns Metabolic Changes: Dehydration, loss of intracellular and extracellular fluids Loss of protein Fluid and electrolyte imbalances Decreased urine output Increased energy expenditure (50 to 100% from basal)  Burns Edema Gastric atony Weight loss Increased serum Potassium levels Management: Immediate Shock Period Day 1 to 3, 4 to 5 Fluid therapy, IV Saline solution Lactated Ringer’s solution – hypovolemic shock, metabolic acidosis Water, dextrose solution  Management: Recovery Period Day 3 to 5 Diuresis IV discontinued Oral solutions (Holdrane’s) administered Monitor for dehydration and over hydration  Management: Secondary Feeding Period Day 6 to 15 Optimum nutrition support Consider depression and anorexia Extra protein and Vitamin C Extra carbohydrates B Vitamins required  Nutrition Therapy for Burns Tube feeding Concentrated oral liquids (Protein hydrolysates) Soft to regular diet High calories, protein and carbohydrates Vitamin C B complex Iron Increase fluids and electrolytes  Nutrition Therapy for Burns Curreri Formula: Total Energy Requirement (Adults) (25 kcal x Preburn body weight Kg) + (40 kcal x % Body surface area burned) Total Energy Requirement (Children) (30 to 100 kcal RDA for age x Preburn body weight Kg) + (40 kcal x % BSA burned) Body Surface Area Burned  Sample Calculation Patient data: 110 lbs pre burn weight, 65 years old, third degree burn on the chest. Calculate for the TER and Protein Requirement TER = (25 kcal X 50 Kg) + (40 Kcal x 18) = 1970 or 2000 Kcal CHON = (1g x 50 Kg) + (3g x 18) = 104g  Nutrition Therapy for Burns Protein Requirement (Adults) (1g protein x Preburn body weight Kg) + (3g x % Body surface area burned) Protein Requirement (Children) (3g protein x Preburn body weight Kg) + (1 x % BSA burned)  Nutrition Therapy for Burns > 10% BSA burn wound, allow 20% of TER for protein; non protein kcal: nitrogen ratio of 100:1 < 10% TBSA burn wound, allow 15% of TER for protein (non protein kcal: nitrogen ratio of 150:1 Protein has 16% nitrogen or 6.25  Non Protein Kcal to Nitrogen Ratio Sample computation for a 2,200 Kcal diet, 65g protein Step 1: Compute for calories from protein (65g x 4 kcal = 260 kcal CHON) Step 2: Subtract protein calories from TER (2,200 kcal – 260 kcal = 1940 kcal Non Protein Calories) Step 3: Compute for the amount of nitrogen in the diet, use the factor 6.25 65g CHON/6.25 = 10.4g of nitrogen Step 4: Divide the total NPC by the grams Nitrogen 1940 kcal NPC/ 10.4g of nitrogen = 186.5 Ratio is NPC:N 187:1 Thank you and God bless!