THE SURGICAL CLIENT
Surgery
stresses the client regardless of whether it is elective or not. If the surgery
is elective, the client’s nutritional status should be evaluated before
surgery; and if improvement is needed, it should be undertaken immediately. A
good nutritional status before surgery enhances recovery. A nutritional
assessment of the client before surgery will be helpful to the dietitian in
providing nutrition that will be accepted by the client after surgery, when
appetite is poor. Improvement of nutritional status will usually mean providing
extra protein, carbohydrates, vitamins, and minerals. The extra protein is
needed for wound healing, tissue building, and blood regeneration. Extra
carbohydrates will be converted to glycogen and stored to help provide energy
after surgery, when needs are high and when clients may be unable to eat
normally. The B vitamins are needed for the increased metabolism, vitamins A
and C and zinc for wound healing, vitamin D for the absorption of calcium, and
vitamin K for proper clotting of the blood. Iron is necessary for blood
building, calcium and phosphorus for bones, and the other minerals for
maintenance of acid-base, electrolyte, and fluid balance in the body. In cases
of overweight, improved
nutritional status includes
weight reduction before surgery whenever possible. Excess fat is a
surgical hazard because the extra tissue increases the chances of infection,
and fatty tissue tends to retain the anesthetic longer than other tissue.
Many
physicians order their clients to be NPO (nothing by mouth) after midnight the
night before surgery. Withholding food ensures that the stomach contains no
food, which could be regurgitated and then aspirated into the lungs during
surgery. If there is to be gastrointestinal surgery, a low-residue diet may be
ordered for a few days before surgery. This is intended to reduce intestinal
residue.
The postsurgery diet
is intended to provide calories and nutrients in amounts sufficient to fulfill
the client’s increased metabolic needs and to promote healing and subsequent
recovery. In general, during the 24 hours immedi-ately following major surgery,
most clients will be given intravenous solutions only. These solutions will
contain water, 5% to 10% dextrose, electrolytes, vitamins, and medications as
needed. The maximum calories supplied by them is about 400 to 500 calories per
24-hour period. The estimated daily calorie requirement for adults after
surgery is 35 to 45 calories per kilogram of body weight. A 110-pound
individual would require at least 2,000 calories a day. Obviously, until the
client can take food, there will be a considerablecalorie deficit each day.
Body fat will be used to provide energy and to spare body protein, but the calorie
intake must be increased to meet energy demands as soon as possible.
Because protein losses
following surgery can be significant and because protein is especially needed
then to rebuild tissue, control edema, avoid shock, resist infection, and
transport fats, a high-protein diet of 80 to 100 grams a day may be
recommended. In addition, extra minerals and vitamins are needed. When
peristalsis returns, ice chips may be given; and if they are tolerated, a clear
liquid diet can follow. (Peristalsis is evidenced by the presence of bowel
sounds.)
Normally in
postoperative cases, clients proceed from the clear-liquid diet to the regular
diet. Sometimes this change is done directly and sometimes by way of the
full-liquid diet, depending on the client and the type of surgery. The average
client will be able to take food within 1 to 4 days after surgery. If the
client cannot take food then, parenteral or enteral feeding may be necessary.
Sometimes following
gastric surgery, dumping syndrome occurs within 15 to
30 minutes after eating. This is characterized by dizziness, weak-ness, cramps,
vomiting, and diarrhea. It is caused by food moving too quickly from the
stomach into the small intestine. It occurs secondary to an increase in
insulin, in anticipation of the increase in food, which never comes.
To prevent dumping
syndrome, the diet should be high in protein and fat, and carbohydrates should
be restricted. Foods should contain little fiber or concentrated sugars and
only limited amounts of starch. Complex carbo-hydrates are gradually
reintroduced. Gradual reintroduction is recommended because carbohydrates leave
the stomach faster than do proteins and fats. Fluids should be limited to 4
ounces at meals, or restricted completely, so as not to fill up the stomach with
fluids instead of nutrients. They can be taken 30 minutes after meals. The
total daily food intake may be divided and served as several small meals rather
than the usual three meals in an attempt to avoid overloading the stomach. Some
clients do not tolerate milk well after gastric surgery, so its inclusion in
the diet will depend on the client’s tolerance.
The food habits of the
postoperative client should be closely observed because they will affect
recovery. When the client’s appetite fails to improve, the physician and the
dietitian should be notified, and efforts should be made to offer nutritious
foods and supplements (either in liquid or solid form) that the client will
ingest. The client should be encouraged to eat and to eat slowly to avoid swallowing
air, which can cause abdominal distension and pain.
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