Samira Jones, PhD, MPH Baptist Health Systems Dietetic
Internship
Slide 2
Introduction- Anatomy & Phys of Intestine Background- SBO
Hospital Admission- R.L. Patient Profile Nutrition Care Process-
Pt. LOS in Hospital Summary/Conclusions
Slide 3
In adults, the small intestine is 19 ft. (6.5 m) and large
intestine is 4.9 ft. (15 cm).
Slide 4
A blockage in normal downward flow of intestinal contents
Epidemiology- Adhesiolysis accounts for 300,000
hospitalizations; 800,000 days of inpatient hospital care, and $1.3
billion in healthcare costs (2006). Etiology- 75% are caused by
post-operative adhesions and hernia from prior GI surgery.
Pathophysiology- SBO may occur in as many as 15% of laparotomy pts.
up to 2 yrs s/p procedure. Pts. Have high risk for re-current
obstruction of 42% over 10 yrs. More than SBO pts. require surgery
with a 5% mortality rate d/t complications.
Slide 7
Clinical Diagnosis Ultrasonography Intraluminal contrast
studies CT scan Once SBO is confirmed Laparotomy is performed to
differentiate between simple and complicated obstruction, severity,
and location.
Slide 8
Three step approach Resuscitation Investigation Therapy
Therapy-Treatment Lysis of Adhesions Bowel resection
Carbohydrates-CHO Simple CHO rather than complex CHO Protein
Severe malnutrition is rare Fats & Fat Soluble Vitamins Higher
risk of malabsorption B-12 High risk of malabsorption
Slide 11
Fluids Challenging to manage with ostomies Electrolytes
Alleviate Na/K+ imbalances
Slide 12
NPO-TPN Bowel rest PO Clear Liquid Regular Liquid Small
frequent meals & low fiber *Individualized
Slide 13
ADA Nutrition Care Manual Recommendations Calories: 25-30
kcal/kg IBW Protein: 1-1.2 or 1.2-1.4 g/kg IBW Fluids: 30 ml/kg or
Per MD
R.L. 22 y.o., AA male; Adopted by foster parents at age 2 yrs
Non-ambulatory: Uses wheelchair Med Hx: Cerebral palsy, Paraplegia-
multiple BLE osteotomies for severe contractures, Hiatal
hernia-Nissen fundoplication s/p 10 yrs, VP shunt s/p 20 yrs Prior
UCDMC admissions- 3 since 2004
Slide 16
Admit date: 5/2/11 Diagnosis: SBO with large hiatal hernia
& stomach in thoracic cavity (CT scan) Signs/Symptoms: PTA Pt.
screened in from nursing for nausea & vomiting for > 3 days
Complained of left/right abdominal pain for several days Poor
intake and appetite > 5 days
Slide 17
Nutrition Assessment Diet order Anthropometrics Labs Diet
history Estimated needs Nutrition Diagnosis Nutrition Intervention-
PES statement Nutrition Monitoring/Evaluation
Slide 18
Initial Nut Assessment 5/5/11- RD Intern Anthropometrics Wt.=
71.7 kg (standing scale); Ht= 56=167.6 cm IBW= 64.5 kg; %IBW= 111
Estimated Nutrition needs 1612-1935 kcal/day(25-30 kcal/kg IBW)
64-97 g protein/day(1.0-1.5 g/kg IBW) Physical appearance:
Abdominal distension Labs: Na 131 L, Glu 115 H, BUN 2 L, ALT 68 H
Eating hx: Per parents, pt. had good appetite and ate typical
American diet PTA. He likes spaghetti, burgers & fries, ice
cream, and junk food.
Slide 19
Diet Order: NPO for GI surgery; TPN- AA 100 g, Dex 150 g,
lipids 20% 250 ml= 1410 kcal @ 58.75 ml/hr PES: Inadequate oral
intake r/t altered GI function d/t small bowel obstruction, as
evidenced by nausea/vomiting 3 days PTA and current NPO x 5 days.
NI-2.1 Risk: High Monitoring & Eval: Pt. will begin at 1400
kcal and advance to goal of 1600 kcal/ml/day as medically
appropriate to meet estimated needs.
Slide 20
Follow-up assessment: RD Intern 5/10/11 Diet order: NPO-TPN
1602 kcal @ 66 ml/hr providing 280 g Dex, 100 g Amino acids, and 28
g Lipid Labs: Na 131 L, Glu 111 H, BUN 7 L PES: Increased nutrient
needs r/t altered GI function as evidenced by pt. currently on TPN
because of NPO > 8 days. NI- 5.1 Risk: High Monitoring &
Eval: Pt. will meet 1000% of estimated needs at goal TPN rate to
preserve LBM while unable to meet PO nutrition.
Slide 21
9 days post hospital admission: 5/11/11 Laparospopic Lysis of
adhesions Hiatal hernia repair Checked Fundoplication- Functional
Bowel Exploration- MD discovered 50 cm of dead ileum*
Slide 22
Follow-up assessment- RD 5/16/11 Diet order: NPO-TPN (100 g AA,
280g Dex, 250 ml 20% lipids)= 1852 kcal @ 66.6 ml/hr (up from 58.4
ml/hr from last assessment) Labs: Glu 162 H PES: Altered GI fxn r/t
to GI surgery as evidenced by KUB findings of severe postoperative
ileus. NC-1.4
Slide 23
7 days s/p GI surgery (2) Externalization of VP Shunt 9 days
s/p GI surgery (3) Laparotomy Abdominal washout End Ileostomy-
lower left quadrant
Slide 24
Diet order: NPO-TPN = 100 g of AA, 280 g Dex and 250 ml of 20%
lipids daily = 1852 kcal/d Labs: Glu, TG, Na, K all WNL; Phosphorus
slightly elevated but pharmacy aware and was addressing it. RD
recommendations: Once GI status permits, Osmolite 1.0 @ 10 ml/hr
advancing 10-20 ml/hr every 6-8 hrs. as tolerated. Goal= 70 ml/hr,
provides 1780 kcals, 75 g protein, 1411 ml free water; flushes and
fluids per MD. Taper PN with goal to discontinue as EN increases.
Modified diet- Low fiber diet once medical status permits.
Slide 25
Diet order: NPO-TPN= 100 g of AA, 280 g Dex and 250 ml of 20%
lipids daily, provides 1602 kcals Labs: Glu 142 H Osteomy output=
710 ml RD recommendations: Advancement to low fiber diet once GI
status permits. Continue PN, but taper with goal to D/C as PO
intake improves. Monitor total energy intake over next 5 days for
goal of 1600 kcals, 77 g protein
Slide 26
Pt. NG tube removed Diet order: PO diet- Regular, low residue
over 24/48 hrs, and PN at same level Output= 1150 ml; 970 ml (1 day
prior) RD recommendations: Pt. tolerated 100% CL diet and 1 meal of
regular diet w/ no complaints of nausea/vomiting, so PN recommended
to d/c with continual advancement to PO at adequate level to meet
needs.
Slide 27
Conversion of ventriculoperitoneal (VP) shunt to ventricular
atrial (VA) shunt d/t pt. experiencing hydrocephalus
Slide 28
Diet order: PO- Modified puree diet Meds: Imodium, Gas-X,
Metamucil Pt. parents requested puree diet b/c they believe pt.
would tolerate it better d/t smoother texture (pt. with poor
dentition) and not completely eating whole foods. Output= 550 ml RD
recommendations: Provide Ensure plus TID and supplemental EN if
inadequate nutrition remains b/c pt. meeting ~65%- 68% of estimated
kcal & protein needs from current PO intake over last 5
days.
Slide 29
Diet order: 75-90 g CHO controlled diet Pt. parents provided
with Ostomy nutrition education handout. Parents advised of foods
to avoid like simple CHO and to consume small, freq meals, and
importance of electrolyte balance and adequate hydration while pt.
has ileostomy. Output= 1350 ml Pt. weight status unable to be
assessed d/t shifts in fluid status.
Slide 30
Diet order: Low fiber, Pediasure TID, snacks (bananas, white
bread PB&J sandwich, tea-BRAT diet) TID Wt. 147 # =66.5 kg
Output= 1400 ml Meds: Protonix, Metamucil, Lomotil, Imodium, Gas-X
RD recd: Pt. will meet at least 70% of est. needs with current
diet. D/C metamucil b/c of its effects on high ostomy output.
Provide MV supplement and monitor fluids. Ostomy output should
estimate < 1 L per 24 hrs.
Slide 31
Malnutrition is common in patients with partial or complete
SBO. In complicated SBO cases, the patient may end up with an
ostomy if part of the bowel is removed or resected. MNT for SBO has
to be individualized based on the location, type, and severity of
obstruction (partial, complete).
Slide 32
Several factors must be considered before diet advancement is
made to ensure optimal nutrition for the patient. Even when a team
is assertive with delivery of nutrition, the role of the RD is
still crucial to monitor the adequacy of the intake and
appropriateness of the order.
Slide 33
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Obstruction: A population-based appraisal. Journal of American
College of Surgeons, 2006; 203: 170-176. Agresta F, Piazza A,
Michelet I, Bedin N, and Sartori A. Small bowel obstruction-
Laparascopic Approach. Surgical Endoscopy, 2000; 14: 154- 156.
Miller G, Boman J, Shrier I, and Gordon PH. Etiology of Small Bowel
Obstruction. American Journal of Surgery, 2000; 180:33-36. Kulaylat
MN and Doerr RJ. Small Bowel Obstruction Surgical Treatment:
Evidence- based and Problem-oriented. National Library of Medicine,
National Institutes of Health, 2001: Washington, D.C. Ihedioha U,
Alani A, Modak P, Chong P, and O'Dwyer PJ. Hernias are the most
common cause of strangulation in patients presenting with small
bowel obstruction. Hernia, 2006; 10: 338-340. Mahan LK and
Escott-Stump S. Krause's Food & Nutrition Therapy, 12th
Edition. 2008; copyright Saunders Elsevier, St. Louis,
Missouri.