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.