nutrition- chapter 22 Flashcards
1
Q
poor nutritional status is associated with
A
- impaired wound healing
- increased risk of post-op infection
- increased necessity of enteral or parenteral nutrition support
- increased morbidity and mortality
- increased hospital stay
- increased cost
- reduced quality of life
*children and elderly at greatest risk
2
Q
dehiscence
A
splitting open of a surgical wound
3
Q
nutrient reserves
A
- nutrient reserves can be built up before elective surgery to fortify a patient
- protein deficiencies are common among pediatric and geriatric hospitalized patients
- sufficient kilocalories are required when increased protein is needed for tissue building
- vitamin and mineral needs increase proportionately
- water balance should be assessed
4
Q
preoperative period
A
- patients are typically directed not to take anything orally for at least 8 hours before surgery
- before gastrointestinal surgery, a fiber-restricted diet may be prescribed
- nonresidue elemental formulas provide complete diet in liquid form
5
Q
emergency surgery
A
- no time for building up ideal nutrient reserves
- reason for maintaining good nutrition status at all times
6
Q
nutrient needs for healing
A
- postoperative nutrient losses are sometimes great, but food intake is often diminished
- catabolism usually occurs after surgery (tissue breakdown and loss exceed tissue buildup)
- weight loss and malnutrition are common among patients who are experiencing catabolic stress, but the maintenance of lean body mass improves the survival of some catabolic patients
- if a patient is not able to resume adequate oral intake within a few days, an alternative form of nutrition support must be considered
7
Q
need for increased protein
A
- building tissue for wound healing
- replace losses from:
- tissue breakdown and blood
loss - body fluid loss from exudates
- tissue breakdown and blood
- controlling edema
- controlling shock by maintaining blood volume
- healing bone
- resisting infection
- transporting lipids
8
Q
post-surgical protein deficiency can cause
A
- poor wound healing
- rupture of 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 and muscle wasting
- increased mortality risk
9
Q
energy
A
- provide sufficient nonprotein kilocalories for energy to spare protein for tissue building
- energy needs increased for extensive surgery or burn patients
- Mifflin–St. Jeor equations:
- Male: BMR = [(10 × Weight in kg) + (6.25 × Height in cm) – (5 × Age in yr) + 5] × injury factor
- Female: BMR = [(10 × Weight in kg) + (6.25 × Height in cm) – (5 × Age in yr) – 161] × injury factor
10
Q
water
A
- prevent dehydration, maintain circulation, prevent complications
- fluid replacement needs to be individualized
- elderly require special attention
- large water losses possible from vomiting, hemorrhage, fever, infection, or diuresis
- IV fluids used initially
- oral fluids used as soon as possible
11
Q
vitamin C
A
- build connective tissue and capillary walls
- parenteral administration protects microvascular functions, decreases length of stay in the hospital for post cardiac-surgery patients, decreases the risk for morbidity, and may be particularly beneficial for critically ill patients with sepsis
12
Q
B vitamins
A
- metabolize protein and energy
- needs rise proportionately to increased protein and energy needs
- B-complex to build hemoglobin
13
Q
vitamin K
A
promote blood clotting for those on long-term antibiotic therapy
14
Q
potassium, phosphorus
A
tissue catabolism may produce deficiencies
15
Q
sodium, chloride
A
fluid loss may affect these minerals
16
Q
iron
A
iron-deficiency anemia may develop from blood loss or inadequate absorption
17
Q
zinc, selenium
A
levels may be low because of inflammatory response
18
Q
general management
A
- routine IV fluids supply hydration and electrolytes, but not energy and nutrients
- oral feeding
- enteral feeding
- parenteral feeding
19
Q
oral feeding
A
- includes variety
- allows more needed nutrients to be added
- stimulated normal action of the GI tract
- early feedings associated with reduced complications, infections, and hospital stay
- progresses from clear or full liquids to a soft or regular diet
- routine house diet
- assisted oral feeding: avoid making patient feel embarrassed or inadequate
20
Q
enteral feeding
A
- nasogastric tube is most common route
- nasoduodenal or nasojejunal tube more appropriate for patients at risk for aspiration, reflux, or continuous vomiting
- tube is inserted through the nose and then passed down the esophagus and into the stomach. It is then passed through the stomach and into the appropriate portion of the small intestine by peristaltic activity or endoscopic or fluoroscopic guidance
- correct placement of the tube is verified by radiography, auscultation, or gastric content aspiration
21
Q
enterostomy
A
- surgical placement of tube at points along the GI tract
- for long-term feedings
22
Q
esophagostomy
A
tube is placed at the level of the cervical spine to the side of the neck
23
Q
percutaneous endoscopic gastrostomy
A
gastrostomy tube is placed through the abdominal wall and into
24
Q
percutaneous endoscopic jejunostomy
A
jejunostomy tube is placed through the abdominal wall, through the duodenum, and into the jejunum
25
Q
enteral feeding formulas
A
- generally prescribed by the physician and clinical dietitian
- wide variety of commercial formulas available
- precautions for using pureed table food for tube feedings:
- will it fit through tube?
- bacterial contamination
- nutrient composition
- does it require hydrolysis?
- must regulate amount and rate
- rate: bolus or continuous feedings
- diarrhea is most common complication
26
Q
parenteral feedings
A
- any method other than one that involves the GI route
- peripheral parenteral nutrition: less than 10 to 14 days
- central parenteral nutrition: for large nutrient needs or full nutrition support for longer periods
- physicians, dietitians, pharmacists, and nurses work together
- must be discussed with patient and/or family first
- often “Clinimix”
27
Q
TPN (total/central parenteral nutrition)
A
- used for full nutrition support for longer periods
- administered via catheter in large central vein (usually subclavian)
28
Q
PPN (peripheral parenteral nutrition)
A
- appropriate for short-term use (less than 10-14 days)
- can be used to supplement enteral feeding
- smaller veins (like in arm) can deliver the less concentrated solutions
- 900 mOsm/L or less
29
Q
GI surgery
A
- may necessitate diet modifications if the surgery alters the normal digestion or passage of food
- requires special nutrition attention
- nutrition therapy varies depending on the surgery site
30
Q
mouth, throat, and neck surgery
A
- requires modification in the mode of eating
- patients cannot chew or swallow normally
- oral liquid feedings: concentrated liquid formula may be provided to ensure adequate nutrition
- mechanical soft diet used to transition between full-liquid and regular diet; fiber supplement may be needed
- enteral (tube) feedings required for radical neck or facial surgery
- the earliest functioning point of access to the GI tract should be used to maintain gut integrity
31
Q
gastric surgery
A
- because the stomach is the first major food reservoir in the gastrointestinal tract, gastric surgery poses special problems in maintaining adequate nutrition
- problems may develop immediately after surgery or after regular diet resumes
- the goals of nutrition therapy are to promote healing, to prevent dumping syndrome and nutrient deficiency, and to minimize complications such as malabsorption and maldigestion
32
Q
gastrectomy
A
- increased gastric fullness and distention may result if gastric resection involved a vagotomy (cutting of the vagus nerve)
- because it lacks the normal nerve stimulus, the stomach becomes atonic and empties poorly
- weight loss is common
- patient may be fed by jejunostomy immediately after surgery
- frequent small, simple oral feedings are resumed according to patient’s tolerance
33
Q
dumping syndrome
A
- common complication of extensive gastric resection
- readily soluble carbohydrates rapidly “dump” into small intestine
- this rapidly entering food mass is a concentrated solution with a higher osmolality compared with the surrounding circulation of blood
- symptoms: cramping, full feeling; rapid pulse; wave of weakness, cold sweating, dizziness; abdominal pain and diarrhea
- can start from 10 minutes to 3 hours after meal
- results in patient eating less food
34
Q
bariatric surgery
A
- typical deficiencies in several micronutrients
- progress from clear liquid to regular diet over about 6 weeks
- thereafter limited to about 1 cup of food per meal
- patients should avoid using a straw to reduce air swallowing, which can cause discomfort
- subject to dumping syndrome
35
Q
gallbladder surgery
A
- cholecystectomy= removal of gallbladder
- laparoscopic 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
36
Q
intestinal surgery
A
- intestinal resections may be required in cases involving tumors, lesions, or obstructions
- when large sections of the small intestine are removed, parenteral nutrition is used with small allowance of oral feeding
- stoma may be created for elimination of fecal waste (ileostomy, colostomy)
- patients need support and practical help with learning about self-care for an ostomy
- progression to a regular diet is important for nutritional value and emotional support
37
Q
rectal surgery
A
- 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
38
Q
special nutrition needs for patients with burns
A
- plan of care influenced by:
- location of burn
- burn severity
- co-morbidities and other injuries
- plan constantly adjusted
- critical attention required:
- amino acid need
- fluid and electrolyte balance
- energy support
39
Q
burn shock or ebb phase
A
- immediate loss of heat, water, electrolytes, protein
- blood volume and pressure drop; urinary output drops; cell dehydration follows
- body temperature and resting energy needs drop in this short time period (to ~ day 2 of care)
- immediate IV fluid therapy with salt solution or lactated Ringer’s solution
- after 12 hours, albumin solutions or plasma
- ideally, nutrition support initiated by 12 hours
40
Q
acute or flow phase (begins ~ 48-72 hours)
A
- tissue fluids and electrolytes are gradually reabsorbed, and the pattern of massive tissue loss is stabilized
-sudden diuresis indicates initial therapy success - constant attention to fluid intake and output to evaluate for dehydration or overhydration
- around the end of first week, bowel function returns and rigorous MNT begins
- the flow phase of hypermetabolism may last weeks to months
41
Q
MNT for burn patients
A
- patients with burns <20% TBSA: can consume an oral meal plan adequate in nutrients, unless the burn site hinders eating
- caloric needs calculated precisely (ideally indirect calorimetry)
- high portion of kilocalories from carbohydrates (55-60%) and moderate amount from fat (<35%)
- high protein intake essential
- high vitamin/mineral intake
- careful intake record
- oral feedings preferred
- enteral or parenteral route may be used if oral intake inadequate; as early as 6-12 hours after injury
- follow up:
- nutrition support for skin
grafting, reconstructive surgery - personal support to rebuild will
and spirit
- nutrition support for skin
42
Q
residue
A
- undigested or unabsorbed food remaining in the colon after digestion
- includes fiber and substances that stimulate contractions of the GI tract
43
Q
exudate
A
a fluid with a high content of protein and cellular debris which has escaped from blood vessels and deposited in tissues or on tissue surfaces
44
Q
stoma
A
opening in abdominal wall that connects with ileum or colon for elimination of waste
45
Q
euvolemia
A
normal blood volume
46
Q
sepsis
A
life threatening immune response to a bacterial infection
47
Q
diuresis
A
increases excretion of urine
48
Q
auscultation
A
listening to the sounds of the GI tract with a stethoscope
49
Q
continuous feeding
A
- enteral feeding schedule
- formula is infused via a pump over a 24hr period
50
Q
bolus feeding
A
- volume of formula is administered by syringe over ~10 minutes
- given several times per day
51
Q
vagotomy
A
cutting of the vagus nerve
52
Q
atonic
A
without normal muscle tone
53
Q
lactated Ringer’s solution
A
- sterile solution of calcium chloride, potassium chloride, sodium chloride, and sodium lactate in water
- replenished fluid and electrolytes
