Diet Therapy forSurgical Conditions Surgery is defined as a “planned anatomical alteration of the human organism designed to arrest, alleviate or eradicate some pathologic process”. Modern surgery underscores the significance of correct diagnosis of the illness and case of the patient prior to and after surgical procedure. While the success of the operation depends primarily on a qualified surgical team and the use of modern techniques, the severity of postoperative complication is linked to other important factors, including nutritional status. The roles of diet and nutrition support in the pre-operative and post-operative stages are emphasized. The Surgical Process There are three phases of surgical process: 1. pre-operative evaluation and preparation for surgery, 2. the surgery procedure itself and 3. the postoperative care. In all these phases, the patient undergoes physiologic and psychological stresses that require comprehensive care. Based on the urgency of operation, surgery comes in two forms: emergency and elective operation. Emergency surgery Is performed when the nature of illness require an immediate intervention ( such as acute appendicitis ). Thus, there is limited time to prepare the patient especially when poor nutrition coexists. In contrast, elective surgery allows reasonable time to prepare the patient before surgery. The crucial role of nutrition to overall care of surgical patient is well recognized and in fact, the overall importance of nutritional support to surgery is now considered the greater the injury. The pattern of protein breakdown is related to the degree of damage in a doseresponse manner (i. Negative Nitrogen Balance The loss of nitrogen from the body is primarily the result of increased excretion of urea and other nitrogenous products in the urine. loss of protein through the injured tissue in individuals with large open wounds. comparable operation . fat stores and body proteins. Thus. . It is designed to produce sufficient calories to meet high metabolic demands from surgery and injury. The net effect in severe cases is increased urinary nitrogen loss. the larger the nitrogen loss). a muscular. Antidiuretic hormone (ADH) secretion increases during the stress response.e. Nitrogen excretion is also dependent on nutritional state of the patient and the size of the lean body mass.Metabolic Response to Surgery Surgery is accompanied by stress response. well nourished person will lose more nitrogen than a depleted individual will after similar. The stress response involves an increase in the secretion of epinephrine. Minor surgery (such as a hernia repair) may evoke little systemic responses. The catabolic responses to surgery or injury vary depending on the extent of tissue damaged. especially skeletal muscles. whereas major surgery or accidental injuries (such as a cardiac bypass surgery or a 60% total body surface flame burn) induce maximal response. increased aldosterone secretion occurs and sodium and fluid are retained. norepinephrine and corticosteroids resulting in breakdown of glycogen. with decreased urine output and retention of fluid. muscle wasting and weight loss. In hypovolemia. The stress response is also intended to maintain the blood volume. and to strengthen bodily resistance to infections. causing anorexia through central nervous system mechanism and increasing body temperature ).) contribute to the catabolic response. leukotrienes. Patients whose weights are nearly within desirable levels are exposed to less surgical risks than obese or underweight patients. Pre-operative Diet The pre-operative diet aims to improve the nutritional status of the patient. to help hasten post-operative recovery. either directly or indirectly ( stimulating elaboration of catabolic hormones. electrolytes. The elaboration of the counter regulatory hormones cortisol. At these sites. Diabetics should be especially attended to. insulin levels are low and then they gradually rise. Nutritional anemia and other deficiencies should be corrected prior to surgery. protein. and these factors play a central role in the response. protein). to build up glycogen reserves. water. Translocation of the Amino Acids The metabolic response to surgery is characterized by the breakdown of skeletal muscle protein and the translocation of the amino acids ( mainly alanine and glutamine ).Hormonal and Inflammatory Response Initially. Inflammatory factors (such as cytokines. although insulin resistance is present. the amino acids serve to enhance host defenses and support vital organ function and wound repair.g. Weight changes should be affected during the pre-operative stage. etc. to prepare him for nutrient losses during surgery (e. to visceral organs and the wound. glucagon and cathecolamines is increased. . This eliminates the possibility of inhaling the vomitus during the anesthesia and reduces the feces in the colon. parenteral feeding is the fast method of nourishing the patient before surgery. Some clinicians prescribe a non-residue is clear liquid diet for several days especially when the surgical site involves the gastrointestinal tract. In emergency cases. gastric lavage ( gastric suction) is administered to remove gastrointestinal contents.e. Intakes of zinc .. i. use a low-calorie diet that includes carbohydrates adequate for glycogen stores. This is gradually restricted to clear liquids and then all foods are withheld for at least 8 hours to empty the stomach. “parenteral” means other than the oral route. If patient is obese. Whenever possible. the surgery is planned and there is ample time to apply the prescribed pre-operative diets. vitamins C and K should be adequate. Diet immediately before surgery Light evening meals is prescribed the day before the surgery. Diet for Emergency Operations For emergency cases.V ) feeding. a non-residue diet is given for several days. . For gastrointestinal operations. Clinically defined or elemental formulas can provide a complete diet in liquid form.Diet for elective surgery In elective surgery. intramuscular or intravenous ( I. a high protein. subcutaneous. high calories diet with vitamin and mineral supplementation is recommended. use it”. While the best route for food is by mouth. This is gradually changed to full liquid diet. Depending on the patients tolerance for oral feeding. Intravenous or tube feeding are resorted to. to provide nutrients in a hurry. . ether totally or in part. The first rule of post-surgical care is to make the patient resume his normal diet food in the gastrointestinal tract hastens peristalsis and stimulates normal digestive function. The rule of thumb is “when the gut works. a soft. and eventually to a regular diet.Post-Operative Diet In general. there are cases when this is not possible. When the patient has recovered from anesthesia effects or as soon as peristalsis is evident. a high calorie. a clear liquid diet is given. nothing is given by mouth (NPO) immediately after the operation. high protein diet is recommended. sweat. renal losses) •Promotes wound healing Liberal Fluid Intake ( total water intake should equal losses by all routes ) •Regulates fluid and electrolytes balance •Replaces fluid losses(e. drainage. etc.) ( Same as in A) Intervals of feeding ( small. Post-Operative Diets High Calories ( 50% or more than RENI ) • promotes glycogen storage prevents ketosis •Extra energy for increased metabolism •Extra CHO spares protein ( Same as in A ) High Protein ( 50% or more than RENI ) •Builds up nitrogen reserves •Increased resistance to infection •Ensures rapid wound healing •Reduces possible edema at the site of wound •Protects liver against toxic effects of anesthesia •Promotes regeneration of hemoglobin •Replaces protein losses •Increases resistance to infection •Promotes wound healing •Restores fluid and electrolyte balance •Hastens return of muscular strength •Promotes blood-building Vitamin and Minerals Supplementation •Catalyzes metabolic reactions in general •Regulates fluid and electrolytes balance •Promotes blood-building and blood-clotting •(same as in A) plus •Prevents dehydration and shock during immediate postoperative stage •Replaces losses during surgery(e. drainage. Pre-Operative Diets B.g.Principle Underlying the Dietary Modifications Dietary Modifications A. more for liquid diets ) •Promotes assimilation and metabolism •Flexible to patient’s tolerance for food ( Same as in A) . blood.g. vomiting . from blood. frequent feeding 6 times a day. renal excretion. High Protein Diet for an Adult Filipino ( 3000kcal. 100g Pro ) No. 2 MF) 10 6 As needed Total 36 6 60 230 30 70 432 24 2 20 56 1+ 103 30 17 50 1+ 98 Energy (kcal) 510 32 240 1000 337 450 120 293 3022 .Food Exchange Milk Vegetable sA Vegetable sB Fruit Rice Meat Fat Sugar Snacks A High Calorie. CHO Pro Fat Exchanges (g) (g) (g) per day 3 As desired 2 6 10 7 (5 LF. of exchange Sample menus 2 1 1 1 2 1 3 Orange juice. sayote-1 cup Fried fleshy fish-with sliced tomatoes Rice Lacatan – 1 large Milk shake and sponge cake 2 3 3 1-3 2 1 Almondigas soup Beef asado with carrots – one half c Rice Custard Milo with milk Crackers Cheese . 1 tall glass Chicken tinola w/sili leaves broth Thigh -1 large. Morning snack: Protein source Bread-butter Fruit juice Lunch: Soup Main dish w/ vegetables and cooking fat Salad Rice Dessert(fruit) Afternoon snack: Milk source Rice exchange Supper: Soup Main dish w/ vegetables & cooking fat Rice Dessert(milk containing) Bedtime snack: Milk beverage w/ sugar Rice exchange Protein source No. 1 tall glass Champorado w/ milk & sugar Toasted dilis Ensaymada butter 1 2 2 Egg sandwish w/ mayonaise 2(meat) 3(fat) 3 2 1 2 Milk Pineapple juice.Meal pattern Breakfast: Fruit Cereal Protein dish Bread Butter Beverage(milk) Sugar 1 tbsp. B.Intravenous Solution Name and Type Indication for Use A. trauma. metabolic acidosis. hepatic coma. excess protein catabolism. Replacement of acute losses of extracellular fluid volume in surgery. hypocalcemia. . Volume replacement for immediate treatment of shock. For prevention of dehydration. Intrapersol with Dextrose D. CV emergencies. ketosis. intractable edema. or shock. multi-Ion MB in D5 water E. diarrhea. C. Poisoning with barbiturates or other systemic agents which are dialyzable or which cause acute renal insufficiency or failure. azotemia and uremia. Provides the principal ions of normal plasma in almost the same proportions as normal plasma. Used as pediatric replacement solution in the treatment of diarrhea and dehydration. hyperkalemia. intestinal or biliary secretions or in potassium losing disease state. burns. Dextrose 5% 10% 20% 30% Source of readily absorbable glucose for quick energy. To maintain fluid and electrolyte with restricted oral intake. Multisol-R/Multisol-R in D5 water F. thrombo-prophylaxis. Multisol M in D5 water G. fractures. Replacement of fluid losses. For patients under stress or when there are losses of gastric. Multisol MK in D5 water H. pre-operative hemo-dilution. Onkovertin 70 in Dextrose 5% Renal failure. Dextrose 5% in Lactated Ringer’s solution Dehydration of any type to replace extracellular fluid loss as in burns. 5.2g 1. The dietary prescription for tube feeding should be specific in kind.8g 24 mg Potassium Sodium Vitamin A Thiamin Niacin Niacin Ascorbic acid 4.5mg 3. amount. .8g 1. The indications for tube feeding are listed in Table 12.1g 5228 IU 1.Blenderized Tube Feeding Approximate Composition of this Blenderized Feeding Calories Protein Fat Carbohydrate Calcium Phosphorus Iron 2000 kcal 98g 65g 255g 1. and total volume for 24 hours. The route of feeding recommended feeding intervals and volume per feeding should be clearly stated. strength or dilution.0mg 203mg Enteral Nutrition Support Tube feeding is method of introducing food through a tube to persons with a functional gastrointestinal tract either as a supplemental nourishment or as the only source of nutrient intake.0mg 3. radiation or chemotherapy Dumping syndrome Obstruction of gastrointestinal tract ( if access is below obstruction ) Esophageal stricture or neoplasm Spasm of pylorus Neoplasm. blind loop syndrome Short bowel syndrome Gluten enteropathy Crohn’s disease Dissacharidase deficiency Radiation damage Abetalipoproteinemia Obstruction of lymph flow Protein-calorie malnutrition Hypermetabolic state Burns Trauma Surgery Fever Intestinal surgery Preparation for hemorrhoidectomy Preparation for instestinal surgery Transition from total parenteral nutrition to conventional foods Renal failure Hepatic failure Inborn errors of metabolism . unconsciousness.5. Indication for Use of Tube feeding Inability to ingest food normally Stupor. drug reactions.Table 12. foreign body or other obstruction of stomach or intestine Psychiatric illness Anorexia nervosa Depression Diversion of flow ( fistulas ) Impairment of digestion and or absorption Pancreatic insufficiency. cerebrovascular accidents Inflammation in central nervous system Cerebral neoplasm Fracture of mandible Oropharyngial neoplasm Head and neck surgery Dysphagia Radiation to head or neck Chemotherapy Multiple sclerosis Physiologic deterrents to food intake Nausea or vomiting in pregnancy. carcinoma Chronic pancreatitis Bile salt insufficiency Bile acid-induced diarrhea. coma. vomiting or diarrhea. etc. A formulas with high osmolality. Generally. monosaccharides. Fats whole protein and starches are less osmotically active. The terms residue pertains to the amount of bulk remaining in the intestinal tract following digestion. and thus. the lower the osmolality of the formula. renal solute load. The renal solute load (RSL) refers to the amount of urea. Patients receiving formulas with a high RSL must monitored carefully for signs of dehydration especially infants. from commercial preparations. and those using jejunostomy feeding tubes. The prepared dilution is 1kcal/ml. If the renal solute load is especially high. the more rapidly it can be infused. especially the undigested and unabsorbed component if food. sodium. disaccharides and electrolytes. diarrhea. The osmolality involves the concentration of solute per unit of solvent and is measured in terms of milliosmoles per kilogram of water (mOsm/kg). It should be well tolerated by the patient with no reaction in the gastrointestinal tract to cause flatulence. administered quickly. burns and fever. nausea.Characteristic of tube feeding and preparation Tube feeding may be prepared from liquid foods using calculated formulas. and stored. Osmolality may not be a problem if the formula is administered slowly or by a constant drip. will draw fluid in to intestine and may result in cramps. A reduction or absence of residue remaining in the intestine is desirable in some preoperative and postoperative patients. or from regular or natural foods liquefied in a homogenizer or blender. The osmolality of tubefeedings is increased by the presence of free amino-acids. Choosing tube feeding preparation physical properties – the physical properties to be considered in tubefeeding formulas are osmolality. easily prepared. those with impaired renal concentration ability and those with increased fluid losses from vomiting diarrhea. the total volume should not exceed 2300 ml/day or 100ml/hr. for patients with gastrointestinal disorders such as Crohn’s diseased or colitis. the patient will become dehydrate. A well balanced diet of natural foodstuff has an osmolality of approximately 600 mOsm/kg of water compared woth serum which is approximately 300 mOsm/kg of water. residue and viscosity. The osmolality is the measure of the ability of a solution to lose or draw water through a semi-permeable membrane. called “blenderized feeding”. A satisfactory tube feeding must be nutritionally adequate. except for prescribed modifications for specific nutrients. If this water is not given. potassium and chloride in the urine. vomiting. It must be inexpensive. a large quantity of water must be provided to excrete it. Osmolality is a critical factor for individual who had gastric surgery. and for patients in transition between intravenous and tube . The mixture should pass the 2mm tube with relative ease. cereals. for septic or pre and post-surgical cases or for those who have experienced trauma. LCT does not add to formula osmolality. applesauce. If fat malabsorption is present. For patients who develop lactose intolerance. Protein may be supplied in formulas as whole protein. Formulas containing larger molecules. or as free amino acids. These are useful for patients with high caloric needs and limited appetites or volume tolerance. Certain individuals with malabsorption or for those under stress may be getting inadequate amounts of these nutrients and should be monitored and . lactose. Individuals receiving high-protein formulas. but 1. and formulas that have a higher caloric content per unit volume tent to be more viscous. Formulas containing MCT must contain some LCT to provide the required essential fatty acids. which contain glycerol and long chain fatty acids and are called long chain triglycerides(LCT). More viscous formulas require a larger tube which is also generally less comfortable for patients.5 and 2. Minerals and Trace Elements: these nutrients are generally provided in commercial formulas in amounts to meet recommended dietary allowances. vegetables. or one that contains medium chain triglycerides (MCT) in place of long chain fatty acids is indicated. Most tubfeeding yield 1 kcal/ml. oligosaccharides and dextrins. glucose. Caloric density considers the energy value of the food in relation to volume. maltodextrins and oligosaccharides saccharides have been used to provide carbohydrate while minimizing formulas osmolality and sweetness. Dietary fiber can be increased by adding banana flakes. in tube feeding. sucrose. It is generally provided in the form of vegetables oils.Viscosity refers to be resistance of a fluid to flow. fruits. who cannot communicate thirst. should be monitored for adequate water intake and fluid and electrolyte balance. lactose free formulas are used. hydrolyzed protein. The more calorically dense formulas also have high osmolarity and high RSL. both the quantity and type of ingredients must be considered in relation to patient’s specific needs. The viscosity of the formula and the caliber of the tube must be compatible.0 kcal/ml formulas are available. Vitamins. such as whole protein compared to amino acids. Carbohydrates may come from many sources including. A formulas low in protein is administered to individuals with renal or hepatic impairment. Dietary fiber is present is formulas containing fruits. particularly those who are unconscious. pureed fruits or tender leafy vegetables and are beneficial for patients with diarrhea and constipation. Nutrient contribution. Fat adds calories to formulas. A high protein formula may be indicated for individuals who are manourished. a formula low in fat. vegetables and cereals. Cornstarch . corn syrup. Precautions must be taken to prevent dehydration and the patient must be monitored carefully. 4. 7. the following will be most useful: 6. use dilute mixture at first about half to concentration. increasing the volume and consistency. coagulation of protein. Total volume should not exceed 100 ml per hour. the flow of the tubefeeding should be very slow at first. are relatively inexpensive. Avoid coarse. strain after blending. Heating the mixture may result in destruction of water-soluble vitamins. Keep prepared blended foods refrigerated until use. To prevent bacterial contamination during preparation. clogging of nasogastric tubes and coagulation of the formula. Try 50 ml of the mixture at hourly intervals. Use homogenized milk instead. As patients condition improves and whether possible. nutritive and dietary prescription by the doctor. steady rate. Use enough liquid for better blending and liquefying (see recommended dilutions in Table 12. Prepared formulas should be refrigerated if not used immediately. 3. then. then gradually increased the concentration and volume until the patients can tolerate 2000ml at 2-3 hours intervals. In preparing tube feeding it is advisable to observe the following: 1. and are more psychologically acceptable since the formula can be perceived as regular food. Never add new formulas to old ones.Cost and Preparation Time House blenderized formulas prepared from regular foods permit flexibility in meeting needs. small amount of liquid food is gradually introduced. until part of the day’s feeding is by . Again. For the continuous drip method. 9. if pumps are used. 8. To initiate tube-feeding. 10.Feeding formulas should not be allowed to hang for longer than 8-hours. food should be given orally. Additional water should be given as needed to meet fluid requirements. formula need to be diluted. The feeding regimen should be adjusted to the patients condition. However. Tube feeding should not be warmed before use. increased gradually but kept in constant. A chilled or cold formulas can be fed without problems if administered slowly. Extension tubing administration set and bag should be changed daily. 5. Use low-fiber fruits and vegetables. fibrous foods that tent to clog the blender. baby foods in bottles may be used. Do not exceed over 300ml of feeding of 3 to 4hour intervals. Intervals of Feeding and Administration Tube feeding may be given as continuous drip or at intervals throughout the day. Plains pasteurized milk is not recommended because the butterfat tends to clump the blender. Discard formulas after 24 hours. For convenience.5) 2. Use feeding containers that are closed to reduce the risk of airborne organism contamination. addition of medications and fluids. •Assess handling technique of the formula. which may clog tubes •Provide adequate fluids . Is there a possibility of contamination ? Could medication be the cause of the diarrhea ( antibiotics. Enteral Feeding Complications and Suggestion for Solution Complication Diarrhea Aspiration Clogged Tubes Constipation Suggestion for Resolving Problem • Assess the administration of the enteral formula. •Enteral tube replacement should be checked if aspiration is suspected •Consider post pyloric placement of tube if aspiration is a reoccuring problem •Flush tube with 50-1150cc of fluid before and after administration of formula or addition of medications •Avoid the use of juice. its administration or handling. consider holding tube feeding for 12 hrs giving only clear liquids. or per physician’s order.Bolus feeding refers to rapid installation of feeding into the GI tract by syringe or funnel.6. •Assess osmolality of the feeding •Consider a fiber containing formula to increase bulk of the stool •If diarrhea continues. Table 12. stool softeners. Patients on enteral feeding may experience complication as a result of the formula. and the number of cc’s per hour for pump administration. Table 12. •Assess for lactose intolerance •If diarrhea is severe. request an antidiarrheal medication and refer to physician •Head of bed should be elevated to 30-45 degrees to avoid aspiration •Gastric residuals should be checked prior to feeding •Enteral feedings should be held if gastric residuals are greater than 100150cc.6 gives a list of potential complication and suggestion for resolving these complications. laxatives or other medications that may cause diarrhea)? •Assess for fever. Formula should be administered at room temperature. tubing. Consider a stool sample to assess for clostridium difficile toxin. carbonated beverages or sugary fluids to flush the tube •Avoid use of crushed medications •Liquid medications may contain sorbital. Assess the volume of the bolus feedings. The majority of patients seldom tolerated this method. drip rate of the drip feeding. potential of flu or other illness. If enteral bags are filled by nursing staff do not allow nursing to add new formula to old formula (“topping off” the bag). Assess for elemental formula. .Abdominal Distention Nausea/Vomiting Contamination of Formula •Assess volume of formula administered for a short time •Assess possibility of lactose intolerance if client is receiving lactose containing formula •Assess for intolerance to fiber containing formula of appropriate •Consider holding feeding for 12 hours or until excessive vomiting passes •Check residual and tube placement •Assess volume of feeding administered for a short time •Consider anti-nauseant. or anti-emetic or anti-gas medication •A change in formula may be necessary. Always clean tops of cans before opening •Clean poles and surrounding areas often •Discard unused formula •Use sanitary techniques for mixing and administering formula. formula should not hang more than 4-8 hrs or according to manufacturer. They can hang for up to 24-48 hours (see manufacturer’s information for details) •Avoid addition of liquids. medications or new formula in a bag that has been hanging for a period of time •If open systems are used. Refer to physician •Closed systems are ideal for avoiding potential contamination. intramuscular or intravenous feeding. level of digestion and absorption. vomiting. It also promotes rapid wound healing and replaces nutrient losses. colostomy. but if the patients cannot tolerate normal eating. If parenteral feeding is the main source if nutrition. TPN solutions are Diet Therapy for Specific Surgical Conditions best prepared by the experts such as a pharmacist pr in industrial laboratories. The decision to use PPN or CPN is based on the number of calories needed and the osmolality of the solution. (centralparenteral nutrition or CPN) is also called total parenteral nutrition (TPN) or intravenous hyperalimentation (IVH). The oral route is always preferred. . anorexia and location of surgery. presence of nausea. parenteral nutrition of PPN). ability to swallow. other nutrients have to be given via the small veins. etc. or centrally into the superior or inferior vena cava or the jugular vein. Parenteral feeding is a means of providing the nutrients by routes other than the mouth and digestive tract. parenteral feeding is the alternative solutions. such as subcutaneous.Parenteral Feeding Pre-surgical and post-surgical feedings are given in a variety of ways that should be specific to each individual depending on the factors like the patient’s nutritional status. etc. ) is to rest the organ involved and avoid irritation at the site of the resection. rectal surgery. A physician trained in this area prescribe and guides the use of TPN. Parenteral feeding can used in addition to enteral feedings or used alone. gastric resection. usually in the arm ( peripheral. The main objective of dietary modification on specific surgical conditions ( such as tonsillectomy. Neck and Esophagus After the surgery in the mouth. Tube feeding is therefore required. resulting in reduced protein digestion. raw vegetables. spicy foods. Some patient tolerate warm water better than ice or cold water. Intestinal motility is increased and there is defective mixing of food woth the intestinal juices. fruits and vegetable purees. 50% of patients often lose weight after gastric surgery. Surgery in the Mouth. Avoid milk products only if patient cannot tolerate them. The second day. cheese. After the fourth day a soft to light diet is prescribed according to individual tolerance. Gastric Surgery as Gastrectomy A partial gastric resection poses less dietary problems compared to a total gastrectomy. strained warm cereals. As the patient’s condition improves. ice creams and popsicles are added. This diet is inadequate in all nutrients and is usually ordered for only one or two days following surgery. the diet will generally progress as follows: 1. toast and crackers. tube feedings become supplemental and oral feeding gradually initiated progressing from clear to full liquids. Chocolate products and red colored beverages (including red gelatin) are not given because they may mask bleeding. some as early as the 6th day. Increase in amounts of fluid given 3. Fat digestion is also impaired due to reduced biliary and pancreatic juices. Bland foods/solid foods as tolerated . ascorbic acid and folic acid. strained warm cream soups. rice porridge (lugao) and mashed potatoes are added to the cold liquid diet. The patients should be able to resume a normal diet after a week. milk. and insufficient mixing of enzymes with the food. Removal of the stomach in part or as a whole reduces not only the reservoir of food but production of pepsin and HCL. then soft to light and finally to regular diets. neck and esophagus. citrus fruits and other related foods until full recovery. It is low in iron. Ice help in mouth or small sips of water. Adequate daily fluid intake ( 3 L for adults and 2 L for children per day ) is important. start with ice chips or sips of cold water progressing with plain gelatin. cold liquids. thiamin. Lack of HCL and the intrinsic factor found in the stomach leads to reduced utilization of iron and vitamin B12. On the third and the fourth day. the patient has difficulty in chewing and or swallowing. butter. After surgery. 2. cold milk and non-irritating fruit juices. gelatin. Parenteral feedings may be indefinitely prolonged if surgery is extensive or major.Tonsillectomy and Adenectomy The first day after the surgery. Avoid hot. it may help to lie down immediately after meals to retard transit to the small bowel. weakness. syncope and diarrhea. 8. 3. 9. the number of which depends on the patient’s tolerance to specific portions of food. 5. All food and drink should be moderate in temperature. raw fruits and vegetables high in fiber) 13. Dumping Syndrome Individuals who have had gastrectomy may experience the “dumping syndrome” characterized be nausea.lactose free products maybe used.Small frequent feeding 5-6 times per day 11.The guidelines must be tailored to each patient’s needs such as surgery. Small amount of milk of milk maybe tolerated than large amounts . found in fruits and vegetables. If there is steatorrhea. Cold drinks tend to cause increased gastric activity.Low fiber low residue diet ( avoid milk. Diet should be low in simple carbohydrate but should be high in complex carbohydrates. The guidelines of the post-gastrectomy diet for dumping syndrome ( especially in cases of total gastrectomy ) are follows: 10. This causes disruption in the water balance leading to the withdrawal of fluid from the blood to the intestine. 6. Small frequent feeding should be given . Liquids should be given 30-60minutes after each meal. high in protein and moderate in fat. Pectin delays gastric emptying time reduces the glycemic response and slows down carbohydrate absorption. 7. If there is milk intolerance .Restricted liquid or a “dry” diet. food tolerances and intolerances and nutritional problems and deficiencies: 1. Avoid fluid at least one hour before and after a meal. .Low carbohydrates to prevent dumping of readily utilized carbohydrates in the jejunum. may be helpful in the treatment of dumping syndrome. use of medium chain triglycerides and MCT oil may be indicated. 2. If “dumping “ is a problem. Foods should be eaten slowly and chewed well. 12. This happens when the stomach contents are emptied into the jejunum at an abnormally fast rate. The dietary fiber pectin. 4. Ostomies An ostomy is the surgical procedure of creating an opening of the stomach wall of the abdomen. If there is increased fluid loss. The use of mineral oil for a few days. small frequent feedings are recommended. diet is progressed from clear to full liquid omitting milk. In ileostomy. Then give a soft or low fiber diet as tolerated. Avoid tough skin from fruits and vegetables and other foods that may cause stoma obstruction. then a low-residue diet until wound has healed and the patient can tolerate the regular diet. It is a procedure that brings movement of the GI tract usually intestinal to the skin surface. Take plenty of fluids ( at least 8 to 10 cups per day ) especially of the ostomy output is excessive. MCT diet (medium chain triglycerides) is prescribe and fat soluble vitamins ADEK are supplemented. A liberal supply of calories and protein ( at least 1. In all cases. rectum and anus is not medically allowed. The main purpose is to evacuate stools or move the bowels when the normal route via the colon. both water intake and electrolytes are replenished. followed by a non-residue diet. but should not be prolonged since mineral oils interfere with the utilization of fat soluble vitamins and some minerals. IV feeding is given for 2 to 3 days until bowel sounds return. helps. Rectal Surgery This condition refers to any operation done the rectum.5 times the recommended nutrient intakes) will speed up recovery and prevent weight loss. In hemorrhoidectomy. Start with clear liquid diet and progress gradually to one low in residue. as in rectal cancer or hemorrhoidectomy. restrict fat and use MCT oil. When steatorrhea occurs. Some physician prescribe a . Gradually introduce fiber as tolerated. Immediately after the surgery. A clear liquid diet is given within the first 24 hours after the operation. caustics (acid or alkalis). anesthesia and major surgery are some of these cases when patients could be in hyper-metabolic states. Vitamin and mineral supplementation is required. prevention of infection. major burns. vitamin D (for efficient utilization of the mineral) and vitamin C (for intercellular cementing substance. electricity or radiation. Burns Burns refer to tissue injury or destruction caused by excessive heat. actual care for the thermal injuries and plastic surgery later as needed. This fluid loss can reduce the blood volume and thus blood pressure. particularly calcium. Water moves from other tissues to the burn site in an effort to compensate for the loss. proteins and fluids. This condition is sometimes called a “hyper-metabolic state”.Fractures and other Mechanical Trauma Current studies indicate that a unique metabolic reaction is triggered by trauma and stress. Diet should be quite high in calories. In cases of serious burns. as well as urine output. Traumatic injury would need 35-40 kcal/kg body weight per day. Treatment involves relief of pain and shock. Glucose is not included in these fluids for the first 2 or 3 days after the burn because it could cause hyperglycemia. phosphorus and magnesium (for calcification). multiple fractures. electrolytes and proteins. the loss of skin surface leads to enormous losses of fluid. which only compound the problem. Shock. friction. Fluids and electrolytes are replaced by intravenous therapy immediately to prevent shock. An example of a diet prescription is 3000 kcal and 120 g protein. . Other nutrients required in wound healing include arginine. all nutrients related to immune function are needed to hasten wound healing. Initial wound healing occurs readily during a period of negative energy balance. Sufficient energy about 2535 kcal/kg body weight is considered necessary to meet metabolic needs and to prevent protein from being utilized as fuel. Diet therapy. and selenium. Zinc. The provision of sufficient fluid is also necessary.Wound healing Wound is a physical injury to the body tissues disrupting the normal continuity of structure. Increased protein of 1. magnesium.0 g/kg body weight is required to promote wound healing and preserve tissue integrity. . particularly when oral intake is suboptimal. Adjunctive enteral support may be necessary to facilitate wound healing.2-2. subsequent healing occurs between the fifteenth day after surgery or trauma. In general. Wound healing involves tissue synthesis and occurs in two phases. vitamin A and vitamin C are also necessary for continued wound healing.