1. Copyright © 2003 Delmar Learning, a Thomson Learning company Section 3 Medical Nutrition Therapy

2. Copyright © 2003 Delmar Learning, a Thomson Learning company Chapter 22 Diet and Surgery, Enteral and Parenteral Nutrition, Burns, Infections, and AIDS

3. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company3 Objectives  Describe the body’s reactions to stress and relate them to nutrition  Explain the special dietary needs of surgical and burn clients  Discuss enteral and parenteral nutrition  Explain the special dietary needs of clients with fever and infection  Explain the special dietary needs of AIDS clients

4. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company4 Homeostasis Homeostasis is a state of physical balance; a stable condition. Normally, the body operates in a state of homeostasis. When the body experiences the trauma of surgery, severe burns, or infections, this balance is upset.

5. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company5 Homeostasis During its response to physical stress, the body signals the endocrine system, which activates a self-protective, hypermetabolic response. Surgery, burns, and infections can create stress. Nutrition plays an important role in the lives of clients undergoing this stress.

6. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company6 Nutritional Care of Surgery Clients Surgery stresses the client. If the surgery is elective, nutritional status should be evaluated before surgery. Extra protein, carbohydrates, vitamins, and minerals may be needed. In cases of overweight, improved nutritional status includes weight reduction before surgery whenever possible.

7. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company7 Nutritional Care of Surgery Clients Clients will usually be NPO (nothing by mouth) after midnight the night before surgery. This ensures that the stomach contains no food, which could be regurgitated and then aspirated during surgery.

8. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company8 Nutritional Care After Surgery In most cases, intravenous solutions are given first 24 hours after surgery. Solutions contain water, 5 to 10% dextrose, electrolytes, vitamins, and medications as needed. Maximum kcal supplied by solutions is 400 to 500 kcal per 24-hour period.

9. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company9 Nutritional Care After Surgery Estimated daily kcal requirement for adults after surgery is 35 to 45 kcal per kilogram of body weight. A high-protein diet of 80 to 100g a day may be recommended. Extra minerals and vitamins are needed.

10. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company10 Your client weighs 192 pounds and has just had major surgery. How many kcal will the client require in a 24-hour period?

11. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company11 First, calculate the client’s weight in kilograms. 192 lbs  2.2 kg/lb = 87.27 kg Next, multiply the client’s weight in kg by the number of kg/lb (35, then 45) to get range. 87kg x 35kcal/kg = 3045 87kg x 45kcal/kg = 3915 Client needs between 3,045-3,915 kcal/day

12. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company12 Nutritional Care After Surgery When peristalsis returns, ice chips may be given and, if they are tolerated, a clear liquid diet can follow. Normally in postoperative cases, clients proceed from the clear-liquid diet to the regular diet.

13. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company13 Nutritional Care After Surgery The average client will be able to take food within 1 to 4 days after surgery. Sometimes following gastric surgery, dumping syndrome occurs within 15 to 30 minutes after eating. Characterized by dizziness, weakness, cramps, vomiting, and diarrhea.

14. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company14 Dumping Syndrome Caused by food moving too quickly from the stomach into the small intestine. To prevent dumping syndrome, the diet should be high in protein and fat, and carbohydrates should be restricted. Gradually reintroduce complex carbohydrates.

15. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company15 Dumping Syndrome Fluids should be limited to 4 ounces at meals. Divide total daily food intake and serve as several small meals in an attempt to avoid overloading the stomach. Some clients do not tolerate milk well after gastric surgery.

16. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company16 Tube Feeding Enteral nutrition includes the forms of feeding that bring nutrients directly into the digestive tract. Tube feedings may be necessary in clients due to unconsciousness, surgery, stroke, severe malnutrition, or extensive burns.

17. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company17 Tube Feeding Nasogastric tube (NG) inserted through the nose and into the stomach or small intestine. Used for periods of 6 weeks or less. Gastrostomy (opening into the stomach) or jejunostomy (opening into the jejunum) may be done surgically if feeding is needed for longer than 6 weeks.

18. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company18 Tube Feeding Numerous commercial formulas available for tube feeding. Polymeric formulas (1-2 kcal/ml) contain intact proteins, carbohydrates, and fats that require digestion. Used for clients that can digest and absorb nutrients normally.

19. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company19 Tube Feeding Elemental, or hydrolyzed formulas (1.0 kcal/ml) contain the products of digestion of proteins, carbohydrates, and fats, and are lactose-free. Used for clients who have limited ability to digest or absorb nutrients.

20. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company20 Tube Feeding Modular formulas (3.8-4.0 kcal/ml) can be used as supplements to other formulas or for developing customized formulas for certain clients. Not nutritionally complete by themselves.

21. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company21 Tube Feeding Methods of administration: Continuous: On-going over 16- to 24- hour period Intermittent: At night, with food eaten during the day Bolus: Given over a 15-minute period

22. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company22 Problems Associated with Tube Feeding The osmolality of a liquid substance means the number of particles per kilogram of solution. When a formula with high osmolality reaches the intestine, the body may draw fluid from the blood to dilute the formula. Weakness, diarrhea can occur.

23. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company23 Problems Associated with Tube Feeding Aspiration can occur (some of the formula enters the lung), causing the client to develop pneumonia. Tube may become clogged, or client may pull the tube out. Placement of tube should be checked with an X-ray to decrease possibility of aspiration. Keep head of bed elevated.

24. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company24 Parenteral Nutrition The provision of nutrients intravenously. Used if the gastrointestinal tract is not functional or if normal feeding is not adequate for the client’s needs. Total parenteral nutrition (TPN) or hyperalimentation is when parenteral nutrition is used to provide total nutrition.

25. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company25 Parenteral Nutrition Peripheral vein used for nutrient solutions needed for two weeks or less. Central vein used for TPN needed for an extended period of time. High blood flow facilitates quick dilution of highly concentrated TPN reducing risk of phlebitis and thrombosis.

26. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company26 Complications of Parenteral Nutrition Infection at site of catheter can cause infection of blood called sepsis. Bacterial or fungal infections can develop in the solution if unrefrigerated for over 24 hours. Abnormal electrolyte levels, phlebitis, or blood clots can occur.

27. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company27 Complications of Parenteral Nutrition Loss of skin surface leads to enormous losses of fluids, electrolytes, and proteins in cases of serious burns. Fluids and electrolytes are replaced by intravenous therapy immediately to prevent shock. Glucose is not included in these fluids for the first 2 to 3 days after the burn, to reduce the risk of hyperglycemia.

28. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company28 Complications of Parenteral Nutrition Enormous increase in energy is needed for the healing process to occur. Protein needs can be as high as 1.5 to 3.0 or more grams per kilogram of weight, and fat intake, 15 to 20% of nonprotein calories. A high-protein, high-kcal diet is used.

29. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company29 Nutrition Therapy for Burn Clients There is an increased need for vitamin C and zinc for healing. Vitamin B is needed for the metabolism of the extra nutrients. The badly burned client needs sufficient fluids to help kidneys hold the unusual load of wastes in solution and to replace those lost.

30. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company30 Nutritional Care of Fevers and Infections Fever is a hypermetabolic state in which each degree of fever on the Fahrenheit scale raises the basal metabolic rate (BMR) 7%. If extra kcal are not provided during fever, the body first uses its supply of glycogen, then its stored fat, and finally its own muscle tissue for energy.

31. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company31 Nutritional Care of Fevers and Infections Protein intake should be increased because of infections (sepsis). Minerals are needed to help build and repair body tissue and to maintain acid- base, electrolyte, and fluid balance. Extra kcal are needed for the increased metabolic rate.

32. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company32 Nutritional Care of Fevers and Infections Extra vitamins are also necessary for the increased metabolic rate and to help fight the infection causing the fever. Extra liquid is needed to replace that lost through perspiration and possibly vomiting and diarrhea, which can accompany infection.

33. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company33 Nutritional Care of the AIDS Client HIV invades the T cells, which are white blood cells that protect the body from infections. When the T cells cannot function normally, the body has no resistance to opportunistic infections.

34. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company34 Nutritional Care of the AIDS Client Opportunistic infections are caused by other microorganisms that are present but do not affect people with healthy immune systems. HIV infection ultimately leads to acquired immune deficiency syndrome (AIDS), which is incurable and fatal.

35. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company35 Nutritional Care of the AIDS Client Persons diagnosed as being HIV-positive should have a baseline nutrition and diet assessment by a registered dietitian. Unhealthful eating habits can be corrected at an early stage of the disease, and future nutritional needs explained.

36. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company36 Nutritional Care of the AIDS Client AIDS clients experience serious protein- energy malnutrition (PEM) and thus, body wasting. This may be referred to as HIV wasting syndrome, which results in hypoalbuminemia and weight loss.

37. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company37 Nutritional Care of the AIDS Client When possible, medications should be given after meals to reduce the chance of nausea. Sores in the mouth or esophagus can make eating painful, and soft foods may be better tolerated than others. Taste can be affected. Avoid spicy, highly acidic, extremely hot or cold foods.

38. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company38 Nutritional Care of the AIDS Client Additional sugar and flavoring may increase the acceptability of liquid supplements. Because of the nausea and diarrhea, sufficient fluids are essential. Tube feeding may be necessary if client has difficulty swallowing or simply cannot eat.

39. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company39 Causes of Nutrient Loss in AIDS Anorexia Cancer Diarrhea Increased metabolism due to fever Certain medications Malabsorption caused by cancer or diarrhea Protein energy malnutrition

40. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company40 Causes of Anorexia in AIDS Medications: Cause nausea, vomiting Oral infections: Diminish saliva, alter taste, cause mouth pain Altered taste: Changes or exaggerates flavors

41. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company41 Causes of Anorexia in AIDS Fever, pain:Depresses appetite Depression: Depresses appetite Dysphagia:Makes swallowing difficult Dementia:May cause client to forget to eat

42. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company42 You are teaching a class about methods to improve the appetite of an AIDS client. Name some of the methods.

43. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company43 Give medications after meals. Offer soft food. Avoid spicy, acidic, and extremely hot or cold foods. Serve frequent, small meals.

44. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company44 Add sugar and flavorings to liquid supplements. Take advantage of the “good” days and offer any food the client tolerates. Talk with the client to help ease concerns about finances, family, and friends.

45. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company45 Conclusion Surgery, burns, fevers, and infections are traumas that cause the body to respond hypermetabolically. This response creates the need for additional nutrients at the same time that the injury causes a loss of nutrients.

46. Chapter 22Copyright © 2003 Delmar Learning, a Thomson Learning company46 Conclusion Care must be taken to provide extra fluid, proteins, kcal, vitamins, minerals, and carbohydrates as needed in these situations. When surgery is elective, nutritional status should be improved before surgery. When food cannot be taken orally, enteral or parenteral nutrition should be used.