samira jones, phd, mph baptist health systems dietetic internship

Samira Jones, PhD, MPH Baptist Health Systems Dietetic Internship

Introduction- Anatomy & Phys of Intestine Background- SBO Hospital Admission- R.L. Patient Profile Nutrition Care Process- Pt. LOS in Hospital Summary/Conclusions

In adults, the small intestine is 19 ft. (6.5 m) and large intestine is 4.9 ft. (15 cm).

A blockage in normal downward flow of intestinal contents

Adhesions 74% Crohns Disease 7% Hernia 2% Neoplasia 5% Misc. 11% Mechanical Obstruction - *Luminal *Extramural

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.

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.

Three step approach Resuscitation Investigation Therapy Therapy-Treatment Lysis of Adhesions Bowel resection

Motility Agents Octreotide Metoclopramide Stool softeners, laxatives Multiple Pain Medications

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

Fluids Challenging to manage with ostomies Electrolytes Alleviate Na/K+ imbalances

NPO-TPN Bowel rest PO Clear Liquid Regular Liquid Small frequent meals & low fiber *Individualized

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

Ileostomy Physical placement Psychological adjustment Diet modification- Fluid and Output tracking

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

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

Nutrition Assessment Diet order Anthropometrics Labs Diet history Estimated needs Nutrition Diagnosis Nutrition Intervention- PES statement Nutrition Monitoring/Evaluation

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.

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.

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.

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*

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

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

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.

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

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.

Conversion of ventriculoperitoneal (VP) shunt to ventricular atrial (VA) shunt d/t pt. experiencing hydrocephalus

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.

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.

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.

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).

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.

Foster NM, McGory ML, Zingmond DS and Ko CY. Small Bowel 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.

samira jones, phd, mph baptist health systems dietetic internship

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