Nutrition care plan for surgical patients
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Transcript of Nutrition care plan for surgical patients
Nutrition care plan for surgical patients
Surgical Nutrition Training ModuleLevel 1
Philippine Society of General SurgeonsCommittee on Surgical Training
Objectives
• To discuss the process of nutrition management of surgical patients
• To discuss the role of the nutrition team
NUTRITION CARE PLAN FORMULATION
The surgical nutrition process
All admitted patients are nutritionally screened
All nutritionally at risk patients are assessed
All high risk patients are given nutrition care plans
Monitoring of the nutrition process is done
Nutrition care plan modification / Discharge
Nutrition Care Plan
Form
Nutritional status
• Severely malnourished?• Feeding access? Oral, GIT, parenteral,
combinations• Need to build up before surgery?• Is there a need for special nutrients?
malnutritionScheduled• esophageal resection• gastrectomy• pancreaticoduodenectomy
Enteral nutrition for 10-14 days
oral immunonutrition for 6-7 days
Early oral feeding within 7 days
yes no
within 4 days
yes
“Fast Track”
no
Parenteral hypocaloric
Adequate calorie intake within 14 days
Enteral access (NCJ)
yes no
enteral nutrition immunonutrition for 6-7 days
Oral intake of energy requirements
yes no
combined enteral / parenteral
no slight, moderate severe
SURGERY
PRE-OPERATIVE PHASE
POST-OP
EARLY DAY 1 - 14
LATE DAY 14
Oral intake of energy requirements
yesnosupplemental enteral diet
Surgical nutrition pathways: Pre-operative phase
Normal to moderate
malnutrition
SURGERY
Severe Malnutrition • Esophageal resection• Gastrectomy• Pancreaticoduodenectomy
Parenteral nutrition + Omega-3-Fatty Acids + Antioxidants (+ glutamine); 6-7 days
Nutritional Assessment
ESPEN Guidelines on Parenteral Nutrition (2009)
Condition: When oral or enteral feeding not possible
Surgical nutrition pathways:Intra & Post-operative Period
While in the OR ask yourself: “is oral feeding possible within 7 days?”
Yes No
Can I feed within 4 days? Needle catheter jejunostomy
• Enteral nutrition (12 hrs)• Better: immunonutrition
If enteral nutrition is inadequate
Supplemental PN
Yes No
“Fast Track” PN
Transition
ESPEN Guidelines on Enteral Nutrition (2006) and Parenteral Nutrition (2009)
Nutrition Care Plan
Physician, Dietitian, Pharmacist
Total calorie and protein requirement
• Guidelines:– Nutritional status – if severely malnourished
• Calories: 20 to 30 kcal/kg body weight• Use actual body weight if not obese
– Capacity to undergo surgery• Normal or low malnutrition level: immediate surgery
Non-protein calories
• Ratio of glucose to lipid content• Issue regarding type of lipids
– Saturated vs. unsaturated– Long chain vs. medium chain triglycerides– Omega-3 vs. omega-6 PUFA, how about omega-9?
Micronutrients
• Electrolytes– Laboratory values– Drug-nutrient interactions
• Vitamins– Water and fat soluble vitamins
• Trace elements
Nutrition Care Plan
Physician, Dietitian, Pharmacist
Physician, Nurse
Nurse, Dietitian, Pharmacist
Nurse, Dietitian, Physician, Pharmacist
Formulation
• Oral supplementation• Enteral nutrition
– Standard vs. special nutrition– Supplemental vs. meal replacement– Issue of blenderized diets
• Parenteral nutrition– Supplemental vs. total PN– Need to include micronutrients in all solutions– Special nutrients (e.g. pharmaconutrition)
Enteral nutrition issues
Commercial Formulas Blenderized Formulas
Uniform contentsSterile
Low viscosityLactose freeDefined caloric density
Daily nutrient variabilityNon-sterile; high bacterial content and other pathogensHigh viscosityDoes not provide adequate caloric density
Gallagher-Alfred. Nutrition Supp Svc 1983; Tanchoco CC, et al. Respirology 2001;6:43-50
Sullivan MM, et al. J Hosp Infect 2001;49:268-273
Pharmaconutrition
Dose Content in preps
Glutamine 0.4 – 0.5 g/kg 12 – 15 g/L
Arginine ? 4 – 16 g/L
Omega-3-fatty acids (EPA)
2 – 6 g/day 1 – 2 g/L
Antioxidants
Carotenoids
Vitamin C,E
>100% daily requirement
Single or combinations
Maximum effect when given at the proper dose
Access and delivery
• Enteral:– Short term vs. long term– need for enteral pumps
• Parenteral– Peripheral vs. central– Single or multiple lumen catheters– Protocols for maintenance
The surgical nutrition process
All admitted patients are nutritionally screened
All nutritionally at risk patients are assessed
All high risk patients are given nutrition care plans
Monitoring of the nutrition process is done
Nutrition care plan modification / Discharge
The team performs the calorie count and fluid balance
The fluid, calorie, and protein intake are recorded and adequacy of intake
is recorded in the patient’s chart
Monitoring issues
Calorie, protein,
fluid balance
form
Nutrient monitor
form
How to implement• Monitoring: everyone is involved
Monitoring
• Fluid balance – avoid fluid accumulation within 4-5 days post op
• Calorie balance• Gastric retention for enteral nutrition• Blood tests:
– BUN high – dialyze– High triglycerides – lower lipid flow– Hyperglycemia – insulin
• Weight once a weekJan Wernermann, “ICU Cookbook”.Franc-Asia Workshop, Singapore, 2003
Nutrition TeamDiagnosisManagementOverall plan
ScreeningEnteral nutritionParenteral nutritionMonitoring
Parenteral nutritionMonitoring
Enteral nutritionMonitoring
NST activity
Policies and guidelines
Patient rounds
NST meeting
Reports on outcome
Updates from other studies
compiled and updated
regular like 3x a week
• difficult cases• coordination issues
monthly, yearly
regular
NST activity/documentation
Outcomes of adequate intake
Adequate intake in surgery patients
Del Rosario D, Inciong JF, Sinamban RP, Llido LO. The effect of adequate energy and protein intake on morbidity and mortality in surgical patients
nutritionally assessed as high or low risk. Clinical Nutrition Service, St., Luke’s Medical Center, 2008.
THANK YOU