williams' basic nutrition & diet therapy chapter 22 surgery and nutrition support copyright...

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)


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)


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


Williams' Basic Nutrition & Diet Therapy

Chapter 14

Food Habits and Cultural Patterns

Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 51

14th Edition

Lesson 14.1: Social, Cultural, and Economic Patterns and Food Habits

Personal food habits develop as part of a person’s social and cultural heritage as well as individual lifestyle and environment.

Social and economic change often results in alterations in food patterns.

American eating patterns are influenced by many different cultures.


Social, Psychological, and Economic Influences on Food Habits (p. 264)

Social structure Groups may be formed by economic status,

education, residence, occupation, family Group affiliation influences food attitudes and

choices Food and social factors

Food symbolizes acceptance and warmth in social relationships

Certain foods trigger childhood memories


Psychologic Influences (p. 265)

Diet patterns Food has many personal meanings Many psychologic factors rooted in childhood

Food and psychosocial development Food relates closely to psychosocial development Toddlers may become “picky eaters” to control

parents Food neophobia (fear of unfamiliar foods) is

normal developmental factor


Marketing and Environmental Influences (p. 265)

Media Peers Convenience items Grocery stores Cartoon characters


Family Income (p. 265)

Low-income families suffer extreme need Illness, hunger, and malnutrition are more common in

this group About 14.3% of Americans live below poverty level


Cultural Development of Food Habits (p. 265)

Food habits grow from many influences Personal Cultural Social Economic Psychological


Cultural Development of Food Habits (cont’d) (p. 266)

Food habits are learned through everyday living and family relationships

Food habits are primarily based on food availability, economics, personal food beliefs

Cultural background and customs largely determine what is eaten

Foods may take on symbolic meaning


Case Study

List three ways your own culture has helped share your personal food experiences. Share with the group if desired.


Traditional Cultural Food Patterns (p. 266)

Shift in focus from “melting pot” to “diversity” American cities retain pockets of ethnic groups Cultural food habits are retained


Religious Dietary Laws (p. 266)

Religious dietary laws Christianity

• Catholic• Protestant• Eastern Orthodox

Judaism Hinduism Buddhism Islam


Jewish (p. 266)

Different dietary laws depending on orthodox, conservative, or reform beliefs

Dietary laws are called Rules of Kashruth; foods prepared according to these laws are kosher

Meat should come only from animals that chew their cud and have cloven hooves; no pork or birds of prey

Meat and milk products are not mixed Shellfish and crustaceans are avoided No eggs with blood spots are eaten


Influence of Festivals (Jewish)(p. 266)

Many traditional Jewish foods relate to festivals of the Jewish calendar

Examples: bagels, blintzes, borscht, challah, gefilte fish, kasha, knishes, lox, matzo, strudel


Muslim (p. 267)

Dietary laws depend on restriction or prohibition of some foods, promotion of other foods

Milk products: permitted at all times Fruits and vegetables: permitted unless fermented Breads and cereals: permitted unless contaminated Seafood and land animals: permitted Pork and alcohol: prohibited


Representative Foods (Muslim) (p. 267)

Bulgur Falafel Fatayeh Kibbeh Pilaf Pita Tabouli


Influence of Festivals (Muslim) (p. 268)

Ramadan 30-day period of daylight fasting Nights often spent in special feasts All Muslims, regardless of condition, observe this

fasting Some patients (e.g., pregnant or breast-feeding)

may have complications


Case Study

Mr. H practices Muslim dietary laws. Discuss these laws in regard to a meal consisting of

pork medallions, milk, fresh salad with lettuce and tomato and cucumber, steamed carrots and pilaf.


Spanish Influences (p. 268)

Mexican Basic foods are dried beans, chili peppers, corn Small amounts of meat and eggs are used Fruit consumption depends on availability and

price Puerto Rican

Food pattern is similar to Mexican Tropical fruits and vegetables are added Basic foods include viandas (starchy vegetables

and fruits), rice, beans


National Food Guides for Mexico and Puerto Rico (p. 269)


Native American (p. 268)

Indian and Alaska Natives Many diverse groups All have a spiritual devotion to the land Food has great religious and social significance Food differs according to what can be grown locally,

harvested or hunted on the land, or fished from local waters


Native American (cont’d) (p. 270) Native American: Southern Arizona American Indian

Food Guide: Choices for a Healthy Life


Influences of Southern United States (p. 270)

African Americans Food patterns developed through creative ability to

turn basic staples into memorable food Traditional breads include hot breads (biscuits,

spoonbread, cornbread) Wide variety of vegetables and leafy greens

(turnip, collard, mustard) are used Pork is a common meat


French Americans (p. 272)

Cajuns in southern Louisiana are descendants of the French colonists of Arcadia (now Nova Scotia)

French culinary background blended with Creole cooking around New Orleans

Foods are strongly flavored, spicy Seafood is abundant


Asian Food Patterns (p. 273)

Chinese Use a wok for quick stir-frying with little fat Vegetables and rice are staples Meat, eggs, and tofu are sources of protein

Japanese Rice is basic grain Many varieties of fish and shellfish used Vegetables usually steamed Diet is high in sodium, low in milk


Southeast Asian (p. 273)

Southeast Asian: Vietnamese, Indonesian, Cambodian, Laotian Rice is a staple Soups are common Fish, shellfish, pork, chicken, and duck are

common Red meat eaten only once or twice a month


National Food Guides for China, Japan, and Korea (p. 274)


Mediterranean Influences(p. 274)

Italian Bread and pasta are basic ingredients Cheese, meats, poultry, fish, sausages, cold cuts,

and vegetables commonly used Olive oil, garlic, herbs, and wine used in cooking

Greek Bread is the center of every meal Cheese, yogurt, vegetables, rice, lamb, and fish

commonly used


Mediterranean Influences (cont’d) (p. 275)


Changes in American Food Habits (p. 275)

Basic determinants Physical Social Psychological

Factors influencing change Income Technology Environment Access to food Vision


Changes in American Food Habits (cont’d) (p. 276)

Changing American food patterns Household dynamics Family meals Pattern of “grazing,” growing portion sizes Fast foods Health and fitness Economical buying


williams' basic nutrition & diet therapy chapter 22 surgery and nutrition support copyright...

Documents

imprint of elsevier

nutrition support copyright

surgery individual nutrition

gastrointestinal surgery

surgery deficiencies

surgery tissue breakdown

optimal nutrition

extensive surgery