By Christine Bannon ARAMARK Dietetic Internships December 14 2014 Abstract Purpose Follow the Nutrition Care Process Case 82 yr old female with small bowel obstruction SBO who required total parental nutrition TPN ID: 934411
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Slide1
Case Report: Nutritional Management of Small Bowel Obstruction
By Christine Bannon
ARAMARK Dietetic Internships
December 14, 2014
Slide2Abstract
Purpose: Follow the Nutrition Care Process
Case: 82
yr
old female with small bowel obstruction (SBO) who required total parental nutrition (TPN)
Previous hospital visit for SBO – noninvasive treatment and low fiber
Hospitalized again for SBO secondary to adhesions
PMH: Uterine cancer requiring hysterectomy
TPN, lysis of adhesions, and right partial colectomy
Discharged after 15 days on oral low fiber
Slide3Disease Description – Small Bowel Obstruction
The small intestine is a complex organ that plays a major role in the absorption of nutrients
When contents of the intestine are blocked and unable to pass freely, this is considered a small bowel obstructions (SBO).
Signs & Symptoms
Abdominal distention
ConstipationVomitingAbdominal pain and crampsNauseaDiarrhea
Slide4Disease Description – Causes
Mechanical
- characterized by the narrowing of the intestinal
lumen
Inflammation
or trauma to the bowelNeoplasmsAdhesions (Most common)HerniasVolvulus (twisted bowel)
Compression
from outside the intestinal
tract
Nonmechanical
- factors that interfere with the muscle action or innervation of the
bowel
Paralytic ileus
Mesenteric
embolus
or thrombus
Hypokalemia
Slide5Evidence-Based Nutrition Recommendations
Title: Reoperation on the Abdomen Encased in Adhesions
Purpose: To determine the short and long-term outcomes after lysis of adhesions
Method: 40 patients who had recently undergone lysis of adhesions were contacted to evaluate the outcome
Results: 1 postoperative death, 24 early complications. 28 out of 31 had resolved SBO from the surgery
Long-term outcomes: all subjects able to tolerate oral feedings
Slide6Evidence-Based Nutrition Recommendations
Title: Burden of Adhesions in Abdominal & Pelvic Surgery: A Systematic Review and
Metanalysis
Purpose: To estimate the burden of complications associated with abdominal adhesions
Method: Analysis of 196 papers from PubMed,
Embase, and Central which reported incidences of adhesion related complicationsResults: Increase risk of developing a SBO in open abdominal/pelvic surgery. Adhesive SBO associated with longer hospital stays.
Slide7Case Presentation
An 82 year old woman is admitted to the hospital after a night of worsening abdominal pain, nausea and vomiting.
Patient was recently admitted one month prior for a SBO which was treated conservatively with no invasive processors. Since then, patient has followed a low-fiber diet.
Once admitted, patient underwent a series of radiographs to diagnose her with another SBO and renal failure secondary to dehydration
Slide8Nutrition Case Process (NPC): Assessment
Past Medical History
Hypertension
High cholesterol
Type 2 diabetes mellitus
HypothyroidismArthritisFractured spine and coccyxOsteoporosisMissing right kidney from birthReflux
Constipation
Hysterectomy from uterine cancer which was last treated with radiation in 2005
Slide9Food/Nutrition Related History
Lack of appetite for one week prior to admission
Follows a low-fiber diet which was prescribed to her since her last hospitalization for SBO
Lactose – intolerant
Home medications can be found in Table 1
Slide10Nutrition-Focused Physical Findings
No appetite at admission
No identified chewing/swallowing issues with good oral health
Trace bilateral edema in lower extremities
Appeared well nourished
No bowel movement for 2 days prior to admission
Slide11Anthropometric Measurements
4’ 9” (57”)
121 pounds (55kg)
BMI of 26.6 = overweight
IBW: 100 pounds
121% of IBW
Slide12Biochemical Data, Medical Test, and Procedures
Went through a series of x-rays and radiographs to confirm SBO diagnosis.
Labs were taken as followed:
Lab
Normal
Patient’s
Rationale
Sodium
136-144
133
(L)
Acute Renal Failure (AFR), dehydration
Potassium
3.6-5.1
3.4 (L)
Obstruction
Glucose
234 (H)
Acute inflammation
BUN
8-20
21
(H)
Dehydration, hypovolemia
Creatinine
0.6-1.1
2.1
(H)
ARF, dehydration,
inadeq
.
dietary protein, reduced muscle mass
Magnesium
1.9
Indicates
wnl
Phosphorous
Not tested
Albumin
1.9 (L)
Acute inflammation
Slide13Nutrient Needs
1138-1365 calories
55-69gm of protein
1138-1369ml of fluid
Protein needs are elevated due to:
Moderate protein depletion (Albumin 2.1 -2.7)Mildly metabolically stressed Nutritional needs are summarized in Table 2.
Slide14ARAMARK Nutrition Status Classification
M
oderate nutritional risk (status 3)
4
points: GI obstructions
3 points: Vomiting 3 points: Poor appetiteTotal of 10 pointsFollow up in 3-5 days
Slide15Malnutrition Identification
Malnutrition diagnosed with 2 out of the 6 Characteristics
Intake (fair to poor longer than 1 week)
Weight loss
Loss of muscle mass
Loss of subcutaneous fatFluid accumulationFunctional status
Chronic vs. Acute Etiology
Inflammation is chronic and mild-moderate degree vs. inflammation is acute and severe degree
Slide16Malnutrition Identification (cont.)
Malnutrition diagnosed with 2 out of the 6
Characteristics
Intake –
Patient reported consuming <75% of her estimated energy needs for longer than a week
Weight loss Loss of muscle massLoss of subcutaneous fat
Fluid accumulation –
edema noted in lower extremities
Functional
status
Chronic vs Acute Etiology
Acute due to
hypoalbuminemia
(1.9)
Slide17NCP: Diagnoses
Altered Gastrointestinal Function (NC-1.4) related to small bowel obstruction as evidenced by abdominal distention, vomiting and lack of bowel movement.
Malnutrition (NI-5.2) related to small bowel obstruction as evidenced by fluid retention and oral energy intake < 50%-75% for one week.
Slide18NCP: Interventions
Medical Interventions
Nasogastric tube was place for suction to prevent further nausea and vomiting
Right Partial Colectomy
Lysis of adhesions
Medications and their rationale the patient was placed on can be found on Table 3.
Slide19NCP: Interventions
Nutrition Interventions
Parental Nutrition (ND 2.2)
Day
1 standard formula: 70gm amino acids, 150gm dextrose, 20gm lipid with 10gm zinc, 100mg thiamine, 1 mg folic acid, 500mg vitamin C, 60mg
seleniumProvides: 990kcal (22kcal/kg ideal wt), 70gm protein (1.5gm/kg ideal wt
)
Justification:
Malnourished
Enteral feeding can not be safely attempted
Nonfunctional gut
TPN expected to be needed for at least 7 days
Slide20NCP: Interventions
Additional consults were needed from nephrology due to patient’s acute renal failure(ARF)diagnosis
Nephrology findings:
ARF was secondary to
dehydration
Intervention: Intravenous fluid needed
Slide21NCP: Monitoring and Evaluation
Parenteral nutrition
formula (FH-1.3.2.1)
Domain: FOOD/NUTRITION-RELATED HISTORY (FH
)Weight (AD-1.1.2)Domain: ANTHROPOMETRIC MEASUREMENTS (AD) Digestive system (mouth to rectum) (bowel function, bowel sounds) (PD-1.1.5)
Domain: NUTRITION-FOCUS PHYSICAL FINDINGS (PD)
Potassium (BD-1.2.7), Magnesium
(BD-1.2.8), Phosphorus(BD-1.2.11), Glucose,
casual(BD-1.5.2)
Domain
: BIOCHEMICAL DATA, MEDICAL TESTS AND PROCEDURES (BD)
Slide22Follow-Ups (F/U)
F/U #1 (11/14)
PES
: Inadequate energy
intake(NI-1.2) related to small bowel obstruction as evidenced by poor appetite.
Intervention: Parenteral Nutrition/IV Fluids (2.2) when ableGoal: Initiate PN when ableAchievement: PN was started F/U #2 (11/15)
PES:
Inadequate
parenteral
nutrition
infusion (NI-2.7)
related
to
day 1 standard
TPN
formula as evidenced by 72.5% of energy needs being met
.
Intervention: Modify volume of parenteral
nutrition (ND-2.2.4), Modify
composition of parenteral
nutrition(ND-2.2.1)
Modified TPN order
: 70gm amino acids, 235gm dextrose, 30gm lipid with 10gm zinc, 100mg thiamine, 1 mg folic acid, 500mg vitamin C, 60mg selenium
Provides:
1380kcal (30kca/kg ideal
wt
), 70gm protein (1.5gm/ideal
wt
)
Goal: Meet 50-75% of nutritional needs
Achievement: PN order was modified and 100% of nutritional needs were reached
Slide23Follow-Ups (cont.)
F/U #3 (11/16
)
PES: Altered nutrition-related laboratory
values (phosphorous) (NC-2.2) related to SBO as evidenced by phosphorus levels of 1.4.
Intervention: Recommend modify composition of parenteral nutrition (ND-2.2.1). Recommend mineral supplement therapy (phosphorous) (ND-3.2.4.6)
Goal
: Meet 50-75% of nutritional needs
Achievement: Phosphorus was
repleted
. Dextrose was unchanged and serum glucose remained elevated
Slide24Follow-Up (cont.)
F/U #4 (11/17
)
PES
: Parenteral Nutrition Administration Inconsistent with Needs (NI-2.10) related to SBO as evidenced by elevated glucose in the 200’s.
Intervention: Recommend modify composition of parenteral nutrition (ND-2.2.1) (decreased dextrose, increased lipid). Nutrition-Related Medication Management (ND-6) to add 0.15units of insulin/gm of dextrose.Modified TPN order: 1800mls total volume, 75ml/
hr
X 24 hrs. 70gm protein, 200gm dextrose, and 42gm lipid. Provides: 1380kcal (30kcal/kg ideal
wt
) and 70gm protein (1.5gm/kg ideal
wt
)
Goal: Blood Glucose >200
Achievement: PN modified. Additional insulin was added. Blood glucose improving in upper 100’s but remains elevated.
F/U #5 (11/18)
PES: Impaired nutrient
utilization (NC-2.1)
related
to ileus as evidenced by no bowel movement
Intervention
: Continue Parenteral Nutrition/IV Fluids (
2.2)
Achievement: PN was continued at recommended rate
Slide25Follow-Up (cont.)
F/U #6 (11/20)
PES
: Altered Gastrointestinal Function (NC-1.4) related to small bowel obstruction as evidenced by
lack of bowel movement/sound.
Intervention: Continue Parenteral Nutrition/IV Fluids (2.2)Goal: Meet 50-75% of nutritional needsAchievement: PN was continued at recommended rate. (+) Hypoactive bowel.F/U #7 (11/21)PES: Altered Gastrointestinal Function (NC-1.4) related to small bowel obstruction as evidenced by lack of bowel movement/sound.
Intervention: Continue Parenteral Nutrition/IV Fluids (2.2)
Goal: Meet 50-75% of nutritional needs
Achievement: PN was continued at recommended
rate
Slide26Follow-Up (cont.)
F/U #8 (11/22)
PES:
Altered Gastrointestinal Function (NC-1.4) related to small bowel obstruction as evidenced by
nausea and lack of bowel movement.
Intervention: Continue Parenteral Nutrition/IV Fluids (2.2)Goal: Meet 50-75% of nutritional needsAchievement: PN was continued at recommended rate. Hypoactive bowel sounds heard. Patient begins to have flatus.F/U #9 (11/23)
PES
: Inadequate oral
intake (NI-2.1) related to TPN order as evidenced by clear liquid diet.
Intervention:
Begin Clear
liquid
diet(ND-1.2.8.3) while continuing
Parenteral Nutrition/IV Fluids (2.2
) at goal rate.
Achievement: Patient tolerating clear liquids well
. Small bowel movement is noted.
Slide27Follow-Up (cont.)
F/U #10 (11/24)
PES:
Inadequate oral intake (NI-2.1) related to TPN order as evidenced
by clear liquid diet.
Intervention: Advance to Full liquid diet (ND-1.2.8.4) when able. Modify rate of parenteral nutrition (ND-2.2.3) to 40ml/hr.Goal: Meet 50-75% of nutritional needs.Achievement: Diet advanced to full liquid diet. TPN rate was reduced.
F/U #11 (11/25)
PES: Inadequate oral intake (NI-2.1) related to TPN order as evidenced by full liquid diet
.
Intervention: Advance
to General/healthful
diet (ND-1.1) when able
. Modify rate of parenteral
nutrition (ND-2.2.3) to be discontinued completely.
Goal: Meet 50-75% of nutritional needs.
Achievement: Diet advanced to regular for lunch. TPN order was discontinued.
Slide28Discharge Care
No driving X 6 weeks
No lifting/baths
Outpatient F/U in 2 weeks
Wear abdominal binder when out of bed X 2 months
Ice for discomfortLow-fiber diet
Slide29Conclusion
SBO is a serious medical and nutritional concern that can lead to lengthy hospital stays. Clinicians needs to monitor GI function daily in order to prevent GI atrophy
TPN plays an essential role in the management of electrolytes and can supply adequate nutrients when enteral feedings can not be done
Patients should be routinely cautioned on the risk and complications associated with adhesions before undergoing any abdominal or pelvic surgery
Slide30Appendix
Table 1
Medication
Rationale
Tylenol extra
strength, 500mg
Pain
Calcium Carbonate, 500mg
Calcium supplement,
antacid
Coreg,
6.25mg BID
Beta-blocker
for hypertension and heart health
Vitamin D3, 1000units
For osteoporosis
Plavix, 75mg
Blood thinner
Levofloxacin, 250mg
Antibiotic
Levothyroxine,
75mg
Synthetic thyroid hormone for hypothyroidism
Lisinopril, 20mg
ACE inhibitor
Flagyl,
500mg q 8hrs
Antibiotic
Omeprazole, 40mg
Proton
pump inhibitor for GI ulcers, heart burn, GERD
Zofran, 4mg q 6hrs
Nausea,
Vomiting
Florastor
Probiotic
Simvastatin, 40mg
Statin
Ambien, 5mg
Gamma-
aminobutyric
acid for insomnia
Appendix
Table 2
Anthropometric Data
Height
Weight
IBW
IBW%
BMI
57”
121#
100#
121%
24.95
Nutrient Needs
REE
Protein
45.45
kg x 25 kcal/kg =
1138
kcal
45.45
kg x 30 kcal/kg =
1365kcal
1138-1365 kcal/day
45.45kg
x
1.2
g/kg =
55
g
45.45
kg x 1.5 g/kg =
69
g
55 – 69 g/day
Slide32Appendix
Table 3
Medication
Rationale
Vitamin
D3
Bone health
Heparin
Anticoagulant
Sliding
Scale Insulin
Control serum glucose
Levothyroxine
Synthetic thyroid hormone for hypothyroidism
Lopressor
Control high
blood
pressor
Protonix
Proton-pump inhibitor
to manage reflux
Sodium
Chloride flush
Provides additional fluid and electrolyte
balance
Slide33Appendix
Table 4
Domain
Problem/Nutrition Diagnosis
Etiology
Signs/Symptoms
Clinical
(NC-1.4)
Altered Gastrointestinal Function
Related to
small bowel obstruction
As evidenced
by
abdominal distention, vomiting and lack of bowel movement.
Intake (NI-5.2)
Malnutrition
Related to
small bowel obstruction
As evidenced
by
fluid retention and oral energy intake < 50%-75% for one week.
Slide34References
1. Mahan LK,
Escott
-Stump S. Krause’s Food & Nutrition Therapy. 13th ed. St. Louis, MO: Saunders Elsevier; 2011:9-10/306-309.
2.
Kulaylat MN, Doerr RJ. Small Bowel Obstruction – Surgical Treatment. National Library of Medicine. 2001. http://www.ncbi.nlm.nih.gov/books/NBK6873/ . Accessed December 14, 2014. 3. Lucey J. Small Bowel Obstruction. NYU Langone Medical Center. http://www.med.nyu.edu/content?ChunkIID=96913 . Accessed December 12, 2014.
4. Harris EA, Kelly AW,
Pockaj
BA et al. Reoperation on the Abdomen Encased in Adhesion. The American Journal of Surgery. 2002:184 (6): 499-504.
dio
: 12488146.
5. Ten
Broek
RPG,
Issa
Y, van
Santbrink
EJP, et al. Burden of adhesions in abdominal and pelvic surgery: systematic review and met-analysis. BMJ : British Medical Journal 2013;347:f5588. doi:10.1136/bmj.f5588.
6. Width M,
Reinhard
T. The Clinical Dietitian’s Essential Pocket Guide. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.
Slide35References
7. ARAMARK Healthcare. Assessment and education policy #2: Nutrition status classification worksheet. Patient Food Services: Policies and Procedures, Volume IV; 2007.
8. White JV,
Guenter
P, Jensen G et al. Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (
Undernutrition). Journal of Parenteral and Enteral Nutrition. 2012: 36(3): 275-283. DOI: 10.1177/01486071124402859. American Dietetic Association. Pocket Guide for International Dietetics & Nutrition Terminology (IDNT) Reference Manual. 3rd ed. Chicago, IL. 2011.10. Bordeianou L,
Yeh
D. Overview of management of mechanical small bowel obstruction in adults.
UpToDate
. http://www.uptodate.com/contents/overview-of-management-of-mechanical-small-bowel-obstruction-in-adults . Accessed December 7, 2014.