Colleen Major Case Study - Website

Medical Nutrition Therapy in
Colostomy Placement
Colleen Abbott
University of Maryland Dietetic Intern
Major Case Study
May 2015
TABLE OF CONTENTS
Executive Summary......3
Case Report...................4
General Information..4
Social History.4
Medical Data..4
Nutrition History.5
Hospital Course of Patient..........7
Medical Treatment7
Nutrition Treatment...9
Case Discussion......14
Medical Considerations.14
Nutrition Therapy15
Implications of Findings to the Practice of Dietetics.16
Appendix A....18
Appendix B....19
Appendix C....21
Glossary.....22
References.....23
EXECUTIVE SUMMARY
According to Dabirian and colleagues 1, intestinal ostomy is a procedure that is
implemented to treat several medical conditions and this therapeutic procedure can be
temporary or permanent, creating many challenges related to quality of life. Study
results showed some of the physical problems associated with an intestinal ostomy
included irritated skin, odor, and noise from the appliance. Emotional concerns
associated with embarrassment were related to leakage, odor, and noise from the
appliance. The researchers found it was important to help these patients to adapt
successfully to the new phase in their lives by providing appropriate pre- and
postoperative education on the intestinal ostomy.
Education materials state specific foods that may cause loose stools or diarrhea are
apple juice, prune juice, dried beans, chocolate, and fried foods to name a few. 2 Some
foods that can help thicken stools are applesauce, bananas, marshmallows, rice, and
pasta. Some odor causing foods include alcohol, beans, onions, cabbage, broccoli, and
cauliflower. Fresh parsley is a natural deodorizer that can help eliminate odor from the
appliance when eaten.
Kim and associates3 evaluated factors to predict postoperative complications in ostomy
takedown surgical procedure related to nutritional status. Results demonstrated a
postoperative severe malnutrition level (defined as albumin <2.8 mg/dL) was statistically
associated with an increase risk for complications. Ostomy patients may have more
nutritional needs because many patients are nutritionally compromised prior to the
takedown surgery procedure. Severe adhesions and a moderate to severe decrease in
body weight were related to a higher rate of overall complications. Complications
associated with this procedure could result in an ostomy needing to be placed in the
future or temporary nutrition support to minimize weight loss. While extensive research
has been done - no one specific measure has been determined to prevent adhesions,
which has limited the development of preventative measures requiring further research. 4
A registered dietitian has a role in intestinal ostomy placement by providing nutrition
education on foods to eat and avoid, as well as, a role in the ostomy takedown by
determining the patients nutrition status and providing any nutrition supplementation
preoperatively to decrease the risk of postoperative complications.
CASE REPORT
GENERAL INFORMATION
The patient, XX, is a 00-year-old, Caucasian female who was admitted to ____ on ____
for abdominal pain, bowel obstruction, acute UTI, and emesis. XX was discharged on
_____.
SOCIAL HISTORY
XX was previously married and her husband passed away. XX has been living semiindependently with a friend. XX reports being responsible for home management
including: laundry, meal preparation, and shopping. XX denies smoking, alcohol or illicit
substances use.
MEDICAL DATA
Past Medical History
XXs past medical history includes endometrial carcinoma (diagnosed in March) with
treatment including hysterectomy, chemotherapy and radiation (July), seizure disorder,
depression, osteoarthritis, right leg chronic lymphedema, chronic bilateral
hydronephrosis, retroperitoneal fibrosis, vancomycin-resistant enterococci infection, and
rheumatoid arthritis.
Past Surgical History
XX has an extensive past surgical history including:
1/22: Exploratory laparotomy with lysis of adhesions, enterolysis, dissection of
retroperitoneal fibrosis takedown of splenic flexture, ureteral sent placement, takedown
of colostomy with anastomosis of transverse colon to descending colon.
7/21: Laparotomy, revision of colostomy, drainage of abscess on the left side of the
abdomen and lysis of adhesions and abscess drainage.
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 intra-abdominal adhesions.
5/6: Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingooophorectomy and lymph node dissection for endometrial cancer.
Admitting Physical Exam
Cachectic-looking female admitted with abdominal distention. Positive for sclerae that
are non-icteric, and amblyopia. Pelvic examination is difficult to perform but she has no
vaginal bleeding.
Surgical Procedures Since Admission
Since admission on 3/19, underwent a diverting loop colostomy with open lysis of
adhesions and placement of colostomy bag on 3/20.
Laboratory Results
Refer to Appendix A
Medications
Refer to Appendix B
Diagnostic Tests with Results
Date
Diagnostic Test
March 19 Abdominal x-ray
March 19 Chest x-ray
March 19 Abdominal CT
March 26 Pelvis x-ray
March 26
March 26
March 30
April 2
April 3
April 5
April 10
April 14
Hip x-ray
Knee x-ray
Chest x-ray
Abdominal x-ray
Chest x-ray
Abdominal x-ray
TEE
Chest x-ray
April 15
Ultrasound
April 16
April 23
TEE
EKG
Results
Nasogastric Tube (NGT) placed
Poor inspiratory effort with no gross acute focal
pulmonary infiltrate
Bowel obstruction
Tubing superimposed upon pelvis, bilateral ureteral
stents
Within normal limits, no acute changes
Normal left and right knees
Right basilar atelectasis, slightly poor inspiratory effort
Mild ileus, markedly-air-distended stomach
No significant changes
No specific gas pattern
Mass attached to the right atrial wall
Left central venous catheter terminates in the region of
the proximal superior vena cava
Status post right sided chest port removal and new left
sided double lumen tunneled PICC line placement
Thrombus attached to catheter in the right atrium cavity
Normal, no significant changes
Food Allergies
The patient has no known food allergies.
NUTRITION HISTORY
Diet History
Patient reports poor appetite prior to admission (PTA) due to abdominal pain. XX was
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, with
variable oral intake at previous admissions ranging from 0-100% oral intake of meals
and supplements. Patient known to enjoy and consume chocolate Ensure Complete
shakes in the hospital and reports consuming Boost Pudding at home.
Weight History
Per patient usual body weight (UBW) is 63.5 kg. The patients ideal body weight (IBW)
is 50 kg using the Hamwi equation for women. LF experienced significant weight loss in
the past 3 months of 19 pounds (13%), which is consistent with severe weight loss.
Date
Weight (kg)
October 2012
May 2014
June 2014
July 2014
January 2015
February 2015
March 2015
81
68.1
70.9
63.6
63.5
58.2
55.2
Source of
weight
Measured
Measured
Patient reports
Measured
Measured
Measured
Measured via
chair scale
%UBW
%IBW
128%
107%
111%
100%
100%
92%
87%
162%
136%
142%
127%
127%
116%
110%
Physical Activity Level

XX ambulates with an assistive device PTA; she used a cane or walker.
Estimated Nutrient Needs
Source
Kcal Requirements Protein
Requirements
Facility Standards 1,439 1,591 kcal
66 83 g (1.2 1.5
(MSJ x 1.3)
g/kg)
EAL
N/A
N/A
Online Nutrition
Care Manual
1,380 1,932 kcal

(25 35 kcal/kg/day
for unintended
weight loss)
N/A
Fluid
Requirements
1,656 1,932 ml
(30 35 ml/kg)
1,439 1,591 ml (1
ml/kcal)
2,320 ml (BSA
equation)
Use of Vitamins/Minerals, Oral Liquid Supplements, and/or Alternative Supplements

Patient reports consumption Boost Pudding at home/ PTA.
Cultural Attitudes That Influence Dietary Intake
XX did not express any cultural attitudes that influence dietary intake.
Past Nutritional Therapy
Date
Diet
10/18
5/26
6/26
7/2
1/29
2/14
Regular
Regular
Clear Liquid
Regular
Regular
Clear Liquid
Average Intake
of Meal
75-100%
100%
-50-75%
0-25%
50-100%
Nutrition
Supplements
-Ensure Complete
Ensure Clear
Ensure Complete
Ensure Complete
Ensure Clear
HOSPITAL COURSE OF PATIENT

6
MEDICAL TREATMENT
Day 1 Patient reported abdominal pain with emesis; minimal urine output.
Abdominal x-ray, chest x-ray and an abdominal CT collectively demonstrated
colonic obstruction. Care focused on possible loop colostomy, but waiting second
opinion. Diet: NPO, Intake: 0
Day 2 Physician consult confirmed the need for a diverting loop colostomy to
resolve issue with obstruction. Surgical procedure included a diverting loop
colostomy and open lysis of adhesions. Case manager informed XX about
discharge plans for a home health skilled nurse for new ostomy care. Diet: NPO,
Intake: 0
Day 3 Patient transferred to ICU post-operatively. Patient c/o generalized pain,
dilaudid PCA infusing continuous and patient demand. Bowel sounds present,
abdomen tender, soft loose stools draining into ostomy. Removal of NGT. Diet:
NPO, Intake: 0
Day 4 Patient transferred to South 6. Diet: NPO, Intake: 0
Day 5 Psych consult to rule out (r/o) suicidal ideation associated with adjustment
to such a difficult situation; no evidence of major depression. Patient awoke at
3:30 am with hallucinations, talking to people, and removing clothes. According to
nursing patients ostomy is draining brown liquid stool and the stoma is beefy red.
Patient had rectal bowel movement that was brown and pasty. Nutrition initial
assessment initiated secondary due to NPO x 4 days and length of stay x 4 days.
Edema on the right lower extremities. Diet: Clear liquid, Intake: unknown, patient
NPO at time of nutrition consult.
Day 6 Patient stable and transferred to South 6. Physical therapy recommended
home discharge with no skilled physical therapy. Diet: Clear liquid, Intake: 100%
of breakfast
Day 7 No medical issues noted. Nutrition follow-up. Diet: Full liquid, Intake: 0% of
breakfast, 100% of lunch
Day 8 Orthopedic consult for complaints of (c/o) left leg, flank and hip pain; the
physician suspected bursitis from inactivity associated with iliotibial band
syndrome and some lumbar stenosis. X-rays of hip and knee were ordered to r/o
any acute complications. Patients diet downgraded due to nausea. Diet: Clear
liquid, Intake: unknown
Day 9 The surgeon noted that a home health skilled nurse was unnecessary
given patients previous history of ostomy. Patient expressed concerns to the
case manager about the need for additional home assistance; XX was provided
with contact information to Meals on Wheels and the Maryland Department of
Aging. Nutrition follow-up. Diet: GI soft. Intake: 100% of meals
Day 10 Patients diet downgraded due to nausea and vomiting. Diet: Clear liquid,
Intake: unknown
Day 11 No medical issues noted. Diet: Clear liquid, Intake: unknown
Day 12 Patient transferred to IMC from South 6 with possible kidney injury,
patient has decreased urine output and elevated creatinine levels of 3.58. Foley
was placed. Patient has red rash in groin and on buttocks. EKG. Diet: Clear
liquid, Intake: unknown
Day 13 Patient stabilized and transferred to North 3. Diet: Clear liquid, Intake:
unknown
Day 14 No medical issues noted. Diet: Clear liquid, Intake: 100% of meals
Day 15 XX transferred from North 3 to IMC with hypokalemia. Patient received
20 meq of KCl and 2 g of Mg Sulfate via IV. Palliative care, consulted to
determine goals of care, recommended increasing OxyContin by 20 mg to help
with constant pain. Nutrition follow-up. Diet: Clear liquid, Intake: 100% of meals
Day 16 Patients temperature was climbing with a Tmax of 38.1. KCl
replacement. Started on Vancomycin. Diet: Clear liquid, Intake: unknown
Day 17 Infectious disease specialist diagnosed XX with methicillin-resistant
Staphylococcus aureus bacteremia (MRSA) noting fever was trending down
since the previous night. Plan for 4-week course of antibiotics. Diet: Clear liquid,
Intake: unknown
Day 18 Patient 50 cc of urine output and 750 ml of NS bolus was given. Walked
the unit with PT. Diet: Clear liquid, Intake: unknown
Day 19 Cardiology consult recommended a trans esophageal echocardiogram
(TEE) to evaluate cardiac valves and a mass located at the tip of the Port-ACath. Transthoracic echocardiography (TTE) demonstrated a 1.8 x 1.7 infected
mass-thrombus attached to the catheter in the right atrium; physicians
questioned type of mass. Diet: Clear liquid, Intake: unknown
Day 20 Patient with r/o infection in the right atrium related to Port-A-Cath.
Cardiology consulted. SLP consulted for a clinical swallowing exam to address
continued patient complaints; SLP recommended GERD precautions and
treatment for xerostomia. Nutrition follow-up. Diet: Full liquid, Intake: 75 100%
of meals/supplements
Day 21 Patient transferred to South 6. Diet: GI soft, Intake: unknown
Day 22 Nutrition follow-up included provision of new colostomy education.
Palliative care notes LF is sad because she has not seen her daughter since
January 20th. Diet: GI soft, Intake: 75% of meals
Day 23 Day 41 Patient followed by staff RDs after intern left. Subsequent
problems prior to discharge include: TTE showing moderate sized spherical fixed
thrombus in right atrium cavity attached to the catheter. Port-A-Cath removal and
to continue with antibiotics through 5/11/15. Skin alteration on buttocks.
NUTRITION TREATMENT
Nutrition Assessment: March 23 (Hospital day 5)
Age: 00 years old
Labs:
Gender: Female
Weight: 55.2 kg
Na
Height: 157.4 cm
K
BMI: 22
Cl
CO2
BUN
Cr
PMH: endometrial carcinoma in March,
status post (s/p) hysterectomy,
Glu
chemotherapy and radiation in July,
Mg2+
seizure disorder, depression,
Phos
osteoarthritis, bowel obstruction s/p
Ca2+
colostomy in June, right leg chronic
Albumin
lymphedema, chronic bilateral
hydronephrosis, s/p ureteral sent
WBC
placement in January, retroperitoneal
Hct
fibrosis, vancomycin-resistant
MCV
enterococci infection, and rheumatoid
Platelet
arthritis.
AST
ALT
Symptoms: Abdominal pain, emesis
Diet History: Regular
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
Medications: Metronidazole,
Pantoprazole, D5 .45% NaCl + KCl 125
ml/hr
Current Diet: NPO

Nutrition Diagnosis utilize PES Statements
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 Intervention Nutrition prescription, Interventions with goals
Nutrition Prescription
Intervention with goals
Kcal: 1,439 1,591 kcal (MSJ x 1.3)
1. ND-1.1 General/healthful diet
Pro: 66 83 g (1.2 1.5 g/kg)
Goal: Recommend clear liquid diet,
Fluid: 1,656 1,932 ml (30 35 ml/kg) 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
Nutrition Monitoring and 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.
Follow-up: March 25 (Hospital Day 7)

2. Inadequate energy intake (NI-1.2) related to poor appetite PTA as evidence by
minimal po intake PTA/variable po intake now.
10

Kcal: 1,439 1,591 kcal (MSJ x 1.3)
Pro: 66 83 g (1.2 1.5 g/kg)
Goal: Recommend a GI soft diet when
Fluid: 1,656 1,932 ml (30 35 ml/kg) medically feasible
Full Liquid Diet
providers
balance
Indicator
Criteria
1. Chocolate Ensure Complete with
breakfast and Orange Magic Cup with
lunch and dinner. (930 kcal 31 g pro)
Follow-up: March 27 (Hospital Day 9)

2. Inadequate energy intake (NI-1.2) related to poor appetite PTA as evidence by
minimal po intake PTA/variable po intake now. --RESOLVED
Kcal: 1,439 1,591 kcal (MSJ x 1.3)
Pro: 55 66 g (1 1.2 g/kg)
Goal: Patient will tolerate diet
Fluid: 1,656 1,932 ml (30 35 ml/kg) advancement
GI Soft Diet
providers
balance
11
Indicator
3. PD-1.1.5 Digestive system
Criteria
breakfast and Chocolate Boost
Pudding with lunch and dinner. (830
kcal 27 g pro)
3. Achieve normal GI function.
Follow-up: April 2 (Hospital Day 15)

2. Inadequate oral intake (NI-2.1) related to current diet order as evidence by
clear liquid diet not meeting nutrition needs.
Kcal: 1,439 1,591 kcal (MSJ x 1.3)
Pro: 64 76 g (1 1.2 g/kg)
Goal: Advance diet as tolerated with
Fluid: 1,905 2,223 ml (30 35 ml/kg) goal of regular diet.
Clear Liquid Diet
providers
balance
Indicator
4. FH-1.3.2.1 Parenteral
formula/solution
Criteria
1. Mixed Berry Ensure Clear x 2 TID
and Gelatein with dinner. (1290 kcal 62
g pro)
4. If patient is unable to tolerate diet
advancement will need to consider
nutrition support (PPN vs. TPN).

12

2. Inadequate oral intake (NI-2.1) related to post op diet advancement; current
diet order as evidence by full liquid diet relatively low in calories and protein.
Kcal: 1,541 1,703 kcal (MSJ x 1.3)
Pro: 70 83 g (1.1 1.3 g/kg)
Full Liquid Diet
providers
Indicator
4. FH-1.2 Food and beverage intake
Criteria
breakfast and lunch, Orange/Wild Berry
Magic Cup with dinner. (990 kcal 35 g
pro)
4. Offer food, fluids, and supplements
as desired/tolerated.

2. Inadequate oral intake (NI-2.1) related to post op diet advancement as
evidence by slow diet advancement, with variable po intake.
Kcal: 1,541 1,703 kcal (MSJ x 1.3)
Pro: 70 83 g (1.1 1.3 g/kg)
GI Soft Diet
providers
balance
4. E-1.5 Recommend modifications
13
Goal: Understand diet education prior

to discharge
goal of regular diet.
Indicator
3. FH-1.2 Food and beverage intake
Criteria
breakfast and lunch, Chocolate Boost
Pudding with dinner. (990 kcal 35 g
pro)
3. Offer food, fluids, and supplements
as desired/tolerated.
CASE DISCUSSION
MEDICAL CONSIDERATIONS
Normal digestion occurs from the mouth to the anus. Digestion starts in the mouth with
amylase creating a bolus of food. Next, the bolus travels down the esophagus and into
the stomach where digestion continues by mixing with hydrochloric acid and digestive
enzymes forming chyme. From the stomach the chyme moves into the small intestine
where most digestion takes place. Along the small intestine the macronutrients,
vitamins, minerals, trace elements and fluid are absorbed. 5 Then, the chyme progresses
to the large intestine where additional water is removed along with electrolytes and a
small amount of the remaining nutrients. 5 Then the waste products are excreted out of
the body through the anus. When someone has a colonic bowel obstruction food is not
able to travel this normal path. Some obstructions require diversion of the colonic
output/feces through an opening in the surface of the abdomen; this opening (stoma)
is connected to an external ostomy bag that collects output. The diversion can be made
in the colon or the ileum depending on where the obstruction occurs. A bag is placed
externally via a stoma, which is created during the surgery, on the abdominal surface.
Fecal matter collects in the bag and is replaced with a new bag once the bag is full.
There are two major types of bowel obstructions, mechanical and functional. A
mechanical obstruction occurs when there is a blockage preventing the movement of
food. A mechanical blockage may be caused by scar tissue from prior surgery
(adhesions), benign or malignant tumors, weakness in the abdominal wall that may trap
a portion of small intestine, a swallowed foreign body, a gallstone (that migrated into the
intestine), a bolus of undigested food, telescoping of the intestines, twisting of the
intestines, narrowing of a portion of the intestines, or small, balloon-shaped pouches on
14
the intestinal wall.6 A functional obstruction is when there is no physical blockage but the
bowels are not moving food through the digestive tract. 7 The prevalence of an intestinal
obstruction is 20% in individuals admitted to hospital with abdominal pain; of the 20%,
80% of the obstructions involve the small intestine. 6 A physical exam checking for
abdominal tenderness and diagnostic testing including an x-ray or a CT scan can
diagnose bowel obstructions.8
Treatment of a bowel obstruction depends on whether the blockage is partial or
completely blocking movement of material through the intestines. A complete blockage
requires surgery, while conservative treatment for partial blockage includes no ingestion
of food (patient made NPO), placement of a nasogastric tube (NGT) to suction out the
stomach contents and use of IV fluids. 6 Large bowel obstructions typically require
surgery and the diseased or non-functioning part of the intestine is removed and
sometimes the lower colon and anus is bypassed with the upper bowel being connected
to the surface of the abdomen with creation of a stoma; fecal output is collected via a
colostomy bag attached to the stoma. 6 The prognosis for someone with a bowel
obstruction is generally good with proper diagnosis and early treatment. The mortality
rate for a large bowel obstruction is 18.8%. 6 Laparoscopic lysis of adhesions has
resulted in lower morbidity, a faster return to a normal diet, and normal bowel function. 6
Those with a colostomy return to normal activities of daily living once recovered from
the surgery. In some cases, the colostomy is only temporary and a second surgery is
required to re-connect the two segments of bowel allowing bowel function to return to
normal.6
XXs bowel obstruction on this admission was a mechanical obstruction most likely
caused by adhesions from the colon surgery in January. She presented with the
common symptoms of abdominal pain and emesis. At the hospital she received an
abdominal CT showing the colonic obstruction. XX had an NGT placed and was made
NPO. The next day XX went into surgery where she had a diverting loop colostomy
placed and open lysis of adhesions. On the third day post-op XXs diet was advanced to
a clear liquid diet. However, the diet was not advanced quickly primarily due to
persistent c/o nausea and post-operative pain. XXs colostomy was functioning properly
after surgery. On day 17 of the hospital stay XX developed a fever and was diagnosed
with MRSA. A thrombus was identified in XXs right atrium related to the Port-A-Cath on
day 19. Wound care was consulted on day 33 for a skin alteration on the buttocks.
These complications do not have direct nutrition implications however; they were the
basis for some of the gastrointestinal symptoms that delayed diet progression.
NUTRITION THERAPY
After a colostomy is placed nutrition concerns primarily include adequate fluids,
electrolytes, and optimizing nutritional status postoperatively.9 The nutrition prescription
postoperatively, according to the Nutrition Care Manual, is to begin clear liquids,
promote adequate fluid intake, and progress to a low-fiber nutrition therapy. 9 Low-fiber
food choices are important because high-fiber foods can be difficult for the body to
digest while the body is recovering, however, high-fiber foods can slowly be added to
15
the diet as the body heals. It is also recommended to avoid odor-causing foods and
gas-producing foods due to the discomfort this may cause the patient. Once stool output
has stabilized, some foods may be added back to the diet one at a time to determine
tolerance.9 The goals of nutrition care with a colostomy are to prevent nutrient
deficiencies by providing nutrition education to optimize as normal a life as possible.
Nutrition education includes recommendations to reduce gas formation and avoid odorcausing foods including foods shown in the table below. In addition patients are advised
to avoid gum, straws smoking, chewing tobacco, and eating too quickly.
Recommendations to reduce odor include avoiding alcohol, asparagus, beans, broccoli,
brussel sprouts, cabbage, cauliflower, eggs, and fish. Spicy foods, fried foods, and
sugary foods may cause diarrhea. Refer to Appendix C for more information on specific
foods that impact ostomy output. According to the Nutrition Care Manual 8, most people
are able to eat normally within 6 weeks of surgery.
XXs diet did not advance as quickly as most individuals. She was NPO for three days
after surgery. Then spent two days on the clear liquid diet and was advanced to a full
liquid diet for one day and then back to a clear liquid diet for one day. The next day she
was advanced to a GI soft diet and when she experience nausea she was placed back
on the clear liquid diet. XX was unable to advance her diet for 10 days due to symptoms
of severe nausea and pain, despite high dose narcotic pain medicine. XX reported liking
the Ensure Clear and wanting two at each meal along with a Gelatin with dinner
providing 1290 calories and 62 grams of protein. These supplements alone were 150
calories under her needs and two grams of protein less than her needs, allowing her to
go so long on a clear liquid diet and not require parenteral nutrition. Most patients who
receive a colectomy do not require parenteral nutrition support but select patients
should be evaluated for PN when the oral diet cannot be progressed postoperatively. By
day 25 in the hospital XX advanced to a regular diet and was able to tolerate it. On day
27 she was placed on a GI soft diet after her TTE procedure and advanced back to a
regular diet three days later.
IMPLICATIONS OF FINDINGS TO THE PRACTICE OF DIETETICS
The need for a colostomy extends to many disorders beyond large bowel obstruction. A
colostomy may be required in certain cases of Crohns disease, ulcerative colitis,
diverticulitis, cancer or trauma to the gastrointestinal tract. Depending on how much of
the colon is bypassed during the placement of the colostomy can impact fluid and
nutrient absorption. It is important for fluid output from the colostomy be monitored to
assure dehydration does not result in settings of high colostomy output. Postoperative, if
the diet is not able to advanced or other complications arise it is important to initiate
nutrition support that best meets the patients needs. A registered dietitian can provide
patient education on post-op issues and diet restrictions to prevent problems
postoperatively. Those restrictions include avoiding odor-producing foods, gasproducing foods, fried foods, spicy foods, and sugary foods. For the lifetime of the
colostomy it is important to follow the postoperatively nutrition instructions to decrease
16
the risk of obstruction, maintain normal fluid and electrolyte balance, reduce excessive
fecal output, and minimize gas and flatulence. 9
17
Appendix A: Laboratory Values

3/23
Na
K
Cl
CO2
BUN
Cr
141
3.1
112
21
6
0.80
Glu
Mg2+
Phos
Ca
Albumi
n
WBC
Hct
128
1.2
2.5
7.4
3.1
MCV
90.5
Platelet
AST
ALT
185
12
17
6
27.5
3/2
5
143
3.7
112
22
5
0.8
4
97
1.2
2.5
8.3
3.1
3/2
7
142
3.5
112
21
6
0.9
0
117
1.2
2.5
8.3
3.1
4/2
4/7
4/9
4/13
4/16
4/20
4/22
4/27
142
2.7
113
19
18
1.3
0
116
1.6
3.3
7.9
2.1
140
3.9
113
21
14
1.0
9
102
1.7
3.3
8.2
2.0
141
4.2
110
20
10
0.78
140
3.6
108
20
9
0.99
142
4.5
108
27
13
0.90
133
4.2
102
22
16
1.01
133
4.3
99
25
21
1.78
134
3.7
100
27
12
0.87
91
1.1
3.3
8.4
2.0
106
1.4
4.4
9.1
2.0
106
1.9
4.4
9.2
2.0
116
1.4
5.0
9.6
2.6
101
2.3
5.0
8.8
2.6
116
2.3
5.0
10
2.6
4.6
28.
1
93.
0
192
12
17
4.5
30.
0
93.
5
187
12
17
7.6
24.
7
95.
0
170
6
7
6.4
23.
5
91.
1
167
11
7
4.4
23.5
4.0
27.8
3.4
25.7
4.9
37.1
6.7
28.8
5.8
32.8
91.8
92.7
94.5
92.3
90.3
91.6
223
11
7
270
11
7
228
11
7
189
8
9
163
8
9
196
8
9
18
Appendix B: Medications as of 4/28/15

Medication
Acetaminophen
Dosage per day

3,900 mg
Function
Pain reliever
Diazepam
10 mg
Anxiety
Docusate
400 mg
Lidocaine topical
1 patch
Methylnaltrexone
12 mg
Mirabegron
25 mg
Mirtazapine
15 mg
Relieving
constipation and
preventing dry,
hard stools
Local anesthetic
by blocking nerve
signals
Treat constipation
caused by opioid
medications
Treat overactive
bladder by
relaxing the
muscles in the
bladder
Antidepressant
Multivitamin
1 daily
OxyCODONE
120 mg
Pantoprazole
40 mg
Proton pump
inhibitor
Pramipexole
--
Dopamine
antagonist to treat
restless leg
syndrome
Anticonvulsant
used for
preventing
migraine
headaches
Topiramate
200 mg
Prevent vitamin
deficiencies
Opioid pain
medication
Nutrition Side Effect

Nausea, loss of
appetite
Nausea, constipation,
dry mouth
Bitter taste, diarrhea,
throat irritation
-Nausea, diarrhea,
stomach pain
--
Increase in appetite,
sore throat, trouble
swallowing, dry
mouth, nausea,
vomiting, diarrhea,
constipation
Upset stomach
Stomach pain,
nausea, vomiting,
constipation, loss of
appetite, dry mouth
Stomach pain,
nausea, vomiting,
weight loss, diarrhea
Constipation,
diarrhea, dry mouth,
loss of appetite,
nausea
Constipation,
diarrhea, dry mouth,
loss of appetite,
nausea, stomach
pain
19
TraZODone
Warfarin
100 mg
6 mg
Antidepressant
Anticoagulant
Zolpidem
10 mg
Treat insomnia
Vomiting
Nausea, vomiting,
stomach pain, altered
sense of taste
Nausea, constipation,
diarrhea, dry mouth
20
Appendix C: Ostomates Food Reference Chart
21
GLOSSARY
Colostomy: a surgical procedure that brings one end of the large intestine through an
opening made in the abdominal wall allowing liquid feces to be drain into a bag attached
to the abdomen.10
Laparotomy: large open incision through the abdominal wall to gain access to the
organs.
Lysis of Adhesions: process of cutting away scar tissue that develops within the body
typically after surgery as part of the healing process. This procedure is done to restore
normal function and relieve pain.11
Transthoracic echocardiography: a transducer releases high-frequency sound waves
and picks up echoes of the sound waves and transmits them into electrical impulses.
These impulses are converted into moving pictures through the echocardiography
machine. These pictures can be two-dimensional or three-dimensional. 12
Xerostomia: dry mouth
22
REFRENCES
1. 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.
2. Escott-Stump S. Nutrition and Diagnosis Related Care. Baltimore, MD: Lippincott
Williams & Wilkins; 2012.
3. 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.
4. Alpay Z, Saed GM, Diamond MP. Postoperative Adhesions: from formation to
prevention. Semin Reprod Med, 2008;26(4)313-321.
5. Mahan LK, Raymond JL, Escott-Stump S. Krause's Food & the Nutrition Care
Process, 13th Edition. St. Louis, MO: Saunders; 2012.
6. Intestinal Obstruction. ReedGroup MD Guidelines:
http://www.mdguidelines.com/intestinal-obstruction. Accessed on May 26, 2015.
7. Small Bowel Obstruction. MUSC Health Digestive Disease Center:
http://www.ddc.musc.edu/public/symptomsDiseases/diseases/smallBowel/smallBow
elObstruction.html. Accessed on May 26, 2015.
8. Intestinal Obstruction. Mayo Clinic: http://www.mayoclinic.org/diseasesconditions/intestinal-obstruction/basics/tests-diagnosis/con-20027567 Accessed on
May 26, 2015.
9. Academy of Nutrition and Dietetics. Nutrition Care Manual:
https://www.nutritioncaremanual.org Accessed on May 26, 2015.
https://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=19799
https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=345
10. 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/patientcare/health-library/treatments-and-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.
23

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Medical Nutrition Therapy in

Physical Activity Level

1,380 1,932 kcal

Use of Vitamins/Minerals, Oral Liquid Supplements, and/or Alternative Supplements

HOSPITAL COURSE OF PATIENT

Diet History: Regular

Current Diet: NPO

Follow-up: March 25 (Hospital Day 7)

Nutrition Intervention Nutrition prescription, Interventions with goals

Follow-up: March 27 (Hospital Day 9)

Follow-up: April 2 (Hospital Day 15)

Follow-up: April 7 (Hospital Day 20)

19-pound (13%) weight loss in 3 months consistent with severe.

Follow-up: April 9 (Hospital Day 22)

Goal: Understand diet education prior

Appendix A: Laboratory Values

Appendix B: Medications as of 4/28/15

Dosage per day

Nutrition Side Effect

Appendix C: Ostomates Food Reference Chart

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