Major case study website

Medical Nutrition Therapy in Colostomy Placement PRESENTED BY: COLLEEN ABBOTT

Objectives  Understand the colostomy procedure.  Identify the medical nutrition therapy related to a

colostomy procedure.  Discuss the implications of findings to the dietetic

practice.

Normal Digestion

Colostomy Procedure

Colostomy  Dependent on where the

obstruction occurs determines the location of the stoma  Diverting fecal output  Temporary or permanent

Stoma Formation  Upper bowel is

connected to the surface of the abdomen creating a stoma.

Bowel Obstruction  Two types ¡ Mechanical6 ÷ Scar

tissue from prior surgery (adhesions) ÷ Benign or malignant tumors ÷ Weakness in the abdominal wall that may trap a portion of small intestine ÷ A gallstone (that migrated into the intestine) ÷ Telescoping of the intestines ÷ Twisting of the intestines ÷ Narrowing of a portion of the intestines ¡

Functional7 ÷ No

physical blockage but the bowels are not moving food through the digestive tract

Case Study MEET XX!

Background  XX  00 year-old  Caucasian  Female  Admitted on 3/19 for: ¡ Abdominal pain ¡ Bowel obstruction ¡ Acute UTI ¡ Emesis

Social History  Widowed  Daughter  XX handles activities of daily living (ADLs)  Denies smoking, alcohol or illicit substances use

Past Medical History  Endometrial carcinoma (diagnosed in March) ¡ treatment including hysterectomy, chemotherapy and radiation (July)  Seizure disorder  Depression  Osteoarthritis  Right leg chronic lymphedema  Chronic bilateral hydronephrosis  Retroperitoneal fibrosis  Vancomycin-resistant enterococci infection  Rheumatoid arthritis

Past Surgical History Date

Procedure

1/22

Exploratory laparotomy with lysis of adhesions, ureteral sent placement, takedown of colostomy

7/21

Laparotomy, revision of colostomy, drainage of abscess on the left side of the abdomen and lysis of adhesions.

7/16

Colostomy via Hartmann procedure, open lysis of adhesions, and repair of hernia that developed at prior surgical site.

6/24

Exploratory laparotomy with diverting loop transverse colostomy, drainage of abdominal ascites, lysis of extensive severe intraabdominal adhesions.

5/6

Exploratory laparotomy, total abdominal hysterectomy for endometrial cancer.

Diet History  Poor appetite prior to admission (PTA) due to

abdominal pain.  Unsure of the date of her last full meal and reported mainly eating soups PTA.  Patient known to nutrition staff from previous admissions Most recently in February ¡ Variable oral intake at previous admissions ranging from 0-100% oral intake of meals and supplements ¡

 Consumes chocolate Ensure Complete shakes in the

hospital and consumes Boost Pudding at home.

Weight History IBW: 50 kg UBW: 63.5 kg Date

Significant weight loss of 19 pounds (13%) in the past 3 months Weight (kg)

%UBW

%IBW

October 2012 81

Source of weight Measured

128%

162%

May 2014

68.1

Measured

107%

136%

June 2014

70.9

Patient reports 111%

142%

July 2014

63.6

Measured

100%

127%

January 2015 February 2015 March 2015

63.5

Measured

100%

127%

58.2

Measured

92%

116%

55.2

Measured via chair scale

87%

110%

Nutrition Assessment  3/20: diverting loop

colostomy with open lysis of adhesions and placement of a colostomy bag  Poor appetite PTA  NPO x 4 days

Labs Na K Cl CO2 BUN Cr Glu Mg2+ Phos Ca2+ Albumin WBC Hct MCV Platelet AST ALT

3/23 141 3.1 112 21 6 0.80 128 1.2 2.5 7.4 3.1 6 27.5 90.5 185 12 17

Nutrition Diagnosis  1. Involuntary weight loss (NC-3.2) related to poor

appetite PTA as evidence by 19-pound (13%) weight loss in 3 months consistent with severe.  2. Inadequate energy intake (NI-1.2) related to poor

appetite PTA/ current diet order as evidence by minimal po intake PTA/ currently NPO not meeting energy needs.

Nutrition Prescription Source Facility Standards EAL

Kcal Requirements 1,439 – 1,591 kcal (MSJ x 1.3)

Protein Requirements 66 – 83 g (1.2 – 1.5 g/ kg)

Fluid Requirements 1,656 – 1,932 ml (30 – 35 ml/kg)

N/A

N/A

1,439 – 1,591 ml (1 ml/kcal)

2,320 ml (BSA equation)

Online Nutrition Care 1,380 – 1,932 kcal (25 N/A Manual – 35 kcal/kg/day for unintended weight loss)

Interventions & Goals  1. ND-1.1 General/healthful diet ¡ Goal: Recommend clear liquid diet, when medically feasible with a goal of a GI soft diet  2. ND-1.3 Schedule of food/fluids ¡ Goal: Patient will receive PO/nutrition support within the next 1-2 days  3. RC-1.4 Collaborate with other providers ¡ Goal: Prevent weight loss  4. ND-3.2.2 Multi-trace elements ¡ Goal: Achieve normal electrolyte balance  5. ND-2.2.7 IV fluids ¡ Goal: Maintain adequate fluid balance

Monitoring & Evaluation Indicator  1. FH-1.3.2.1

Parenteral formula/ solution  2. FH-1.2.1.3 Liquid meal replacement or supplement  3. AD-1.1.4 Weight change

Criteria  1. If unable to initiate

diet in 1-2 days, consider TPN to meet nutrition needs.  2. Ensure Clear TID (600 kcal 21 g pro) when diet is advanced to a clear liquid diet.  3. Check weight daily to trend.

Nutrition Follow-Ups  5 follow-ups ¡ Prevent weight loss ¡ Nutrition supplements ¡ Monitoring diet advancement ¡ Achieving normal electrolyte balance

Hospital Stay Progress • Colostomy Day 2 procedure

Day 11

• Nutrition assessment Day 5

• Mass found on Port-A-Cath.

Day 19

• Clear liquid diet • Complaints of nausea and vomiting

Day 8

Day 10

• GI soft diet

Day 21

• Clear liquid diet

• GI soft diet

• New colostomy nutrition education Day 22

Day 23 – 41 The patient’s care was taken over by the RD staff

Medical Nutrition Therapy

Postoperative Colostomy Diet

Clear liquid

Full liquid

Regular GI soft

• Low-fiber • High-fiber

Nutrition Education OSTOMATES FOOD REFERENCE CHART For individuals who have had ostomy surgery, it is important to know the effects of various foods on ileal output. The effects may vary with the remaining portion of functioning bowel.

Listed below are some general guidelines of the effects of foods after ostomy surgery. Use trial and error to determine your individual tolerance. Do not be afraid to try foods that you like, just try small amounts.

Stoma Obstructive Apple peels Cabbage, raw Celery Chinese vegetables Corn, whole kernel Coconuts Dried fruit Mushrooms Oranges Nuts Pineapple Popcorn Seeds Gas Producing Alcoholic bev.

Beans Soy Cabbage Carbonated bev.

Cauliflower Cucumbers Dairy products Chewing gum Milk Nuts Onions Radishes

Odor Producing Asparagus Baked Beans Broccoli Cabbage Cod liver oil Eggs Fish Garlic Onions Peanut butter Some vitamins Strong cheese Color Changes Asparagus Beets Food colors Iron pills Licorice Red Jello® Strawberries Tomato sauces Constipation Relief Coffee, warm/hot Cooked fruits Cooked vegetables Fresh fruits Fruit juices Water Any warm or hot beverage

Increased Stools Alcoholic bev.

Whole grains Bran cereals Cooked cabbage Fresh fruits Greens, leafy Milk Prunes Raisins Raw vegetables Spices Odor Control Buttermilk Cranberry juice Orange juice Parsley Tomato juice Yogurt Diarrhea Control Applesauce Bananas Boiled rice Peanut butter Pectin supplement (fiber) Tapioca Toast

 Avoid gas producing

foods  Avoid odor producing foods  Avoid swallowing air Chewing gum ¡ Using straws ¡ Eating quickly ¡

Nutrition Implications to the Dietetic Practice  Colostomy extends to many disorders beyond large bowel

obstruction. ¡ ¡ ¡ ¡

Crohn’s disease Ulcerative colitis Diverticulitis Cancer or trauma to the gastrointestinal tract

 The amount of colon bypassed impacts the fluid and

nutrient absorption.  Fluid output should be monitored to prevent dehydration.  Nutrition support is needed if the diet is not able to advance timely.  Nutrition education for a new ostomy.

References 1.

2.

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4.

5.

6.

Dabirian A, Yaghmaei F, Rassouli M, Tafereshi MZ. Quality of life in ostomy patients: a qualitative study. Dove Medical Press, Ltd. 2011;5 1-5.

Escott-Stump S. Nutrition and Diagnosis – Related Care.

Baltimore, MD: Lippincott Williams & Wilkins; 2012.

Kim MS, Kim HK, Kim DY, Ju JK. The influence of nutritional assessment on the outcome of ostomy takedown. J Korean Soc Coloproctol. 2012;28(3)145-151.

Alpay Z, Saed GM, Diamond MP. Postoperative Adhesions: from formation to prevention. Semin Reprod Med, 2008;26(4)313-321.

Mahan LK, Raymond JL, Escott-Stump S. Krause's Food & the Nutrition Care Process, 13th Edition. St. Louis, MO: Saunders; 2012.

Intestinal Obstruction. ReedGroup MD Guidelines: http://www.mdguidelines.com/intestinal-obstruction. Accessed on May 26, 2015.

References Small Bowel Obstruction. MUSC Health Digestive Disease Center: http://www.ddc.musc.edu/public/symptomsDiseases/diseases/ smallBowel/smallBowelObstruction.html. Accessed on May 26, 2015.

Intestinal Obstruction. Mayo Clinic: http://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/ basics/tests-diagnosis/con-20027567 Accessed on May 26, 2015.

Academy of Nutrition and Dietetics. Nutrition Care Manual: https://www.nutritioncaremanual.org Accessed on May 26, 2015.

7.

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https://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=19799 https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=345

Colostomy. MedlinePlus: http://www.nlm.nih.gov/medlineplus/ency/article/002942.htm.

Accessed on May 26, 2015.

11. Lysis of Adhesions. Mount Sinai Hospital: http://www.mountsinai.org/patient-care/health-library/treatmentsand-procedures/lysis-of-adhesions. Accessed on May 26, 2015.

12. Echocardiogram. MedlinePlus: http://www.nlm.nih.gov/medlineplus/ency/article/003869.htm.

Accessed on May 26, 2015.

10.

Questions?

THANK YOU