3/24 3/26 3/27. Urine output improved è D/C IV LR

Transcription

1 3/24 3/26 Urine output improved è D/C IV LR 3/27 Residual <100ml è NGT clamped Loose stools è check for C-diff è Negative New meds: aztreonan, morphine, percocet

2 3/28 Pt vomits 3 times Gastroparesis New meds: zofran Ambulated 3/29 Pt slightly dehydrated è ½ 25cc/hr New med: erythromycin 3/30 Calorie count posted Psych consulted for anxiety New meds: ativan

3 GOALS 1. Advance to post-gastrectomy diet as tolerated by pt to avoid gastroparesis 2. Increase po intake to >50% within 3 days PLANS -Change to nocturnal TF to increase appetite and optimize intake during the day -Small frequent feeds appropriate -Drink beverages in between meals -Order a calorie count to document exact po intake -Educate pt and family on postgastrectomy diet guidelines -Continue to provide pt with preferred food and beverages.

4 3/31 N/V occur è Blake drain inserted è straw-colored fluid suctioned from J-tube site 4/1 Calorie count not completed 4/2 Poor po, pt not hungry New calorie count posted 4/3 Pt extremely thirsty New meds: amlodipine, atenolol

5 Date Wt Na+ K+ BUN Creat Glu Ca Hgb Hct MCV Palb /Alb A1C 3/ Alb 3.8 3/23 132# Palb 7.6 Alb % 3/27 139# /30 140# / /

6 Sodium (Na+): (hyponatremia) with edema, severe diarrhea/vomiting, hyperglycemia, malabsorption Calcium (Ca+): (hypocalcaemia) with hypoalbuminemia, diarrhea, malabsorptions, diarrhea, acute pancreatitis Hemoglobin (Hgb): with anemia, cirrhosis Hematocrit (Hct): with anemia, blood loss, hemolysis, cirrhosis Prealbumin (Palb): with acute catabolic states, stress, surgery, malnutrition, low protein intake

7 Drug Name Classification Side Effects Heparin Anitcoagulant N/V, ab pain, GI bleed, black tarry stools, é K, TG, chol Metoprolol Antihypertensive N/V, dyspepsia, diarrhea, é K, é TG Protonix Antiulcer/Antigerd gastric acid secretions, é gastric ph, nausea, ab pain, diarrhea, é gastrin, vitb12, é chol, é glu, é creat Narcan Opioid antagonist N/V, diarrhea, HTN, edema Aztreonan Antibiotic Altered taste, N/V, diarrhea, é creat Morphine Analgesic/Narcotic wt, é thirst, dehydration, dyspepsia, dysphagia, gastric motility, N/V, diarrhea Percocet Analgesic/Narcotic Anorexia, dry mouth, dyspepsia, gastritis, N/V, diarrhea, Na KCl Electrolyte GI irritation, N/V, ab pain, diarrhea, é K, é Cl

8 Drug Name Classification Side Effects Zofran Antiemetic/Antinauseant Ab pain, diarrhea, K Erythromycin Antibiotic é gastric motility, epigastric distress, N/V, diarrhea, pancreatitis Ativan Antianxiety wt, é appetite, é wt, é thirst, N/V, diarrhea Discharge Medications Amlodipine Antihypertensive Dysphagia, nausea, edema Atenolol Antihypertensive é TG, HDL, é K, é uric acid, é BUN MVI Multivitamin Ferrous Sulfate Hematinic/Antianemic Anorexia, Zn, N/V, dyspepsia, diarrhea, dark stools, é H/H, é fe, false Ca Ascorbic Acid Vitamin C N/V, dyspepsia, gastric cramps, diarrhea, edema, é Ca excretion, Na excretion

9 4/2 NPO Jevity 50cc/hr via J-tube 4/3 Breakfast: ½ cup farina, 8oz 1% milk, Ensure Plus Lunch: Nothing Dinner: 3 oz. fish (tilapia), 1/3 cup mashed potatoes Nocturnal TF: Jevity 50cc/hr x 8 hours (10pm-6am)

10 Nutrient Requirements (average) Total Average Intake Total Average Intake (w/out TF) Total Kcal 1,650 1, Protein (gm) Fat (gm) Carbohydrate (gm)

11 1,800 1,500 Calories 1, Nutrient Requirements Total intake Intake w/out TF Kcals Protein (cal) Fat (cal) CHO (cal)

12 Assessment Monitoring/ Evaluation NCP Diagnosis Intervention

13 SFH Dietitians (and Dietetic Intern) remained an integral part of the Interdisciplinary Plan of Care for E.W. throughout her stay E.W. was marked as a HIGH RISK patient, so she was seen every 1-3 days by a dietitian for close monitoring Nursing staff administered appropriate tube feeding orders and documented rates hourly Diet orders were promptly modified as patient toleration shifted Calorie counts were posted to evaluate po intake Labs were drawn daily and as requested

14 Transferred to rehab at Our Lady of Consolation (Medicare would only cover 14 days at the hospital) Dr.- Pt overall doing well and continues to improve Pt referred to DeMatteis Outpatient Center Diet order Post-gastrectomy diet Small meals and snacks (5-6x/day) NCS Drink between meals No carbonated beverages Protein at each meal Ensure supplements Medications Amlodipine Ferrous Sulfate Atenolol Vitamin C Protonix MVI

15 Postoperative Nutritional Effects of Early Enteral Feeding Compared with Total Parental Nutrition in Pancreaticoduodenectomy Patients Purpose: Assess the nutritional status and clinical outcomes of patients s/p Whipple according to nutritional method between EEN and TPN Methods/Materials: Randomized, single center, parallel group trial 40 patients over age 18 (mean age of 61) who received PD with malignant periampullary pathology at Gangnam Severance Hospital between May December 2008

16 Assessment of nutrition Weight Laboratory parameters Patient Generated Subjective Global Assessment POD # 7, 14, 21, and 90 Post-Op Nutrition Support: Pt s were divided into 2 groups Enteral feeding- starting w/in 24hr post-op at a rate of 20mL/hr (increasing by 20mL/day unit reaching 25kcal/kg) Total Parenteral- starting on POD#1 w/ solution of 25kcal/kg Patients were given sips of water POD#4-5, and then transitioned to a regular diet within 7 days, or as tolerated

17 RESULTS Transition to an oral diet was quicker in the EEN group Hospital stay was shorter in the EEN group 1 st BM took ~ ½ the time in the EEN group than TPN group 34% of patients had post-op complications, similar rates in both groups EEN Group TPN Group Prealbumin Results Mean prealbumin (mg/l) Pre OP POD 7 POD 14 POD 21 POD 90 Fig. 3. Mean prealbumin and transferring levels on preoperative day and on days 7, 14

18 RESULTS (cont.) No significant difference in the rate of serum albumin change No significant difference in the rate of pancreatic leakage (one of the leading post-op complications) Weight change: EEN group- wt gradually decreased until POD# 14, and rapidly recovered on POD #21 TPN group- wt gradually decreased until POD# 90

19 CONCLUSION Early Enteral Nutrition in gastrointestinal surgery should be recommended whenever possible. The benefits of EEN have been demonstrated to be more physiological, better preventative in morphologic and functional alteration of the gut system, and less expensive.

20 American Dietetic Association. (2011). Pocket Guide for International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process. Chicago: American Dietetic Association. Beers, M. H., Porter, R. S., Jones, T. V., J. L., & Berkwits, M. (Eds.). (2006). The Merck Manual of Diagnosis and Therapy (18 th ed). White house Station, NJ: Merck Research Laboratories. DeVita, V. T., Rosenberg, S. A., & Lawrence, T. S. (2008). Cancer: Principles and Practice of Oncology. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. Facing Pancreatic Cancer. (2012). Retrieved March 24, 2012, from Pancreatic Cancer Action Network: section_facing_pancreatic_cancer/learn_ about_pan_cancer Gottschlich, M. M, (2007). The A.S.P.E.N Nutrition Support Core Curriculum. Silver Spring: American Society for Parenteral and Enteral Nutrition. Langhorne, M. E., Fulton, J. S., & Otto, S. E. (2007). Oncology Nursing. St. Louis: Mosby/Elsevier. Martin, J. A., & Moser, J. (2010, January 18). Ampullary Carcinoma: Epidemiology, Clinical Manifestations, Diagnosis, and Staging. Retrieved March 24, 2012, from UpToDate: Pancreatic Cancer: Integrative Treatment Program. (n.d.). Retrieved March 27, 2012, from Cancer Treatment Centers of America: pancreatic-cancer/pancreatic-cancer-information.cfm Park, J. S., Chung, H.-K., Hwang, H. K., Kim, J. K., & Yoon, D. S. (2011). Postoperative Nutrition Effects on Early Enteral Feeding Compared to Total Parental Nutrition in Pancreaticoduodenectomy Patients. Journal of Korean Medical Society, 27, Pronsky, Z. M., & Crowe, S. J. (2010). Food Medication Interactions. Birchrunville: Food-Medication Interactions. Reber, H. A. (2011, October 11). Pancreaticoduodenectomy (Whipple Procedure): Techniques. Retrieved March 24, 2012, from UpToDate: com/ contents/pancreaticoduodenectomy-whipple-procedure-techniques

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