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Lauren Hoover
KNH 411
September 20, 2016
Gastrointestinal Case Study #13
Gastrointestinal Surgery with Ostomy
I. Understanding the Disease and Pathophysiology
1. Describe the partial colectomy procedure. How does this change the
function of the gastrointestinal tract?
A partial colectomy involves the surgical removal of a portion of the patient’s
colon, in this case 80 centimeters of Ms. Watson’s ascending/transverse colon, and
the anastomosis of the colon to the surface of the skin with colostomy, bypassing the
remaining colon and rectum (Nelms, Sucher, Lacey, p424). The function of the
gastrointestinal tract is altered in regards to the path of food ingested. The food will
travel from the stomach, where some digestion begins to occur, to the small
intestine, where some remaining digestion and nutrient absorption occurs. Instead
of the chyme traveling through the entire colon, the waste will exit into the
colostomy bag. The colon usually functions to absorb water and electrolytes,
therefore, fluid and electrolyte balance could be altered (Nelms, Sucher, Lacey,
p424-425).
2. What is a colostomy? What kind of fecal output can Ms. Watson expect?
A colostomy is when the rectum or part of the large intestine is removed and
the end of the colon is surgically attached to the stoma. The individual utilizes a
pouch appliance to collect waste products (Nelms, Sucher, Lacey, p424). The
opening, or stoma, eventually shrinks to the size of a nickel and the output from the
stoma will depend on its location along the digestive tract. Depending on the exact
position of the colostomy will determine the consistency of the output. Since Ms.
Watson’s colostomy is located on the ascending/transverse portion of the colon, her
output will slightly less formed as it is earlier up in the large intestine and the stool
has still has high water content. The odor will be of a main concern as well (Mahan,
Escott-Stump, Raymond, p639).
3. The physician has ordered a consult for Ms. Watson for teaching regarding
the care of her ostomy. What is an enterostomal therapist? Describe this
specialist’s training and what he or she will most likely teach Ms. Watson.
An enterostomal therapist is the health professional who deals with
consulting the patient and the patient’s family on what to expect and how to handle
a specific procedure that leads to a stoma and ostomies (Mahan, Escott-Stump,
Raymond, p639). The specialist will talk to Ms. Watson about proper ostomy care,
any dietary and fluid alterations, and ways to incorporate this change into a daily
lifestyle. This specialist also should provide follow up care with ongoing counseling,
education and checking for complications. The therapist will teach Ms. Watson how
to empty the pouch and any type of maintenance in regards to keeping the site
clean. The therapist will tell give Ms. Watson tips, such as taking small bites and
chewing thoroughly, eating at the same times each day, eating smaller meals more
often, avoiding spicy, sugary, and fried foods, limiting onions, eggs, fish, broccoli,
beans, and cabbage due to their tendency to cause odor or gas production, avoiding
straws, smoke, gum, and drinking at least 8-10 cups of fluids per day (Nelms, Sucher,
Lacey, p425).
II. Understanding the Nutrition Therapy
4. What is the typical postoperative sequence for nutritional intake? How long
will Ms. Watson be NPO?
After surgery, the patient will slowly be transitioned to an oral diet. Studies
have shown that early oral feedings after lower (post-operative day 1 or 2) are
tolerated by most patients. The progression begins with liquids and will proceed as
tolerated to a low-residue diet with 4 to 6 small feedings per day. Foods that might
not be completely digested, causing possible stoma obstruction, should be avoided
for the first 6-8 weeks. Generally, oral intake should resemble the regular diet by
around the 8th week post-operatively. Ms. Watson will be no longer NPO once a clear
liquid diet is tolerated (Nelms, Sucher, Lacey, p425-426).
5. What are the nutrition therapy recommendations for someone with a
colostomy? How would this be different if she had an ileostomy?
For someone with a colostomy, the nutrient recommendations include
avoiding tough meats , fibrous vegetables, dried fruits, fruit skins, seeds, and
popcorn. The patient should eat slowly, chew thoroughly, and drink adequate fluids.
Foods that cause odors should be limited and small, frequent meals are
recommended. Foods like yogurt, rice, bananas, applesauce, and pasta are
recommended, especially in the first few weeks (Nelms, Sucher, Lacey, p425-426).
Since the colon was resected, some vitamin and mineral requirements might be
affected. These include Vitamin K, Biotin, Sodium, Chloride, Potassium, as well as
short-chain fatty acids and water (Nelms, Sucher, Lacey, p387).
For a patient who has an ileostomy, vitamin B12 injections and Vitamin C and
folate supplementation might be required. Patients look to physiologic reasons for
intolerances to foods and since gastric emptying is more rapid than after a
colostomy, absorption of nutrients might be better from cooked, shredded, or
pureed fruits and vegetables (Mahan, Escott-Stump, Raymond, p640). Depending on
how much of the small intestine is resected will determine the adjusted
requirements for some vitamins and minerals. These include fat-soluble vitamins,
water-soluble vitamins, B-complex vitamins, Calcium, Phosphorus, Magnesium, Iron,
Chromium, Manganese, Molybdenum, Selenium, and others (Nelms, Sucher, Lacey,
p387).
III. Nutrition Assessment
6. Evaluate Ms. Watson’s %UBW and BMI.
Ms. Watson’s ED admitting weight was 165 pounds. Post-operatively, 24
hours later, she weighed 163 pounds. Therefore, her %UBW is:
(163 pounds/165 pounds) x 100 = 98.8%.
Ms. Watson is 1.2% below her usual body weight over a 24 hour period, due to her
procedure. While this rate of weight loss should not be continued long-term, some
weight loss is expected after having this operation.
Ms, Watson’s current BMI is:
163 pounds/2.2 = 74.1 kg
64 inches x 2.54 = 162.6 cm/100 = 1.63 m
74.1 kg/(1.63 m)^2 = 27.9
A BMI of 27.9 puts Ms. Watson in the overweight category.
(Mahan, Escott-Stump, Raymond, p166)
7. Calculate Ms. Watson’s energy and protein requirements.
Since Ms. Watson is in a post-operative state, her usual body weight, 165
pounds, will be used to calculate her energy and protein requirements. I will use the
Miflin-St. Jeor equation to calculate her energy requirements.
REE = 10 x 75 kg + 6.25 x 162.6 cm – 5 x 61 years - 161
REE = 1300 kcal
REE x PAL (1.5) = 1300 x 1.5 = 1950 kcal
(Mahan, Escott-Stump, Raymond, p24)
Protein requirements = 0.8 grams/kg body weight
75 kg x 0.8 = 60 grams of protein
(Nelms, Sucher, Lacey, p66)
8. Identify any significant and/or abnormal laboratory measurements for Ms.
Watson. Explain possible mechanisms for the abnormal labs.
Ms. Watson’s laboratory measurements show that she has an elevated Creactive protein level, 1.3 on 11/2 and 1.1 on 11/3. C-reactive protein is released in
the body during periods on inflammation. Since, Ms. Watson just underwent and
operation, her body is healing itself and some inflammation will occur, therefore this
level should not be worried about, especially since the level has already decreased
one day post-operative (Nelms, Sucher, Lacey, p59).
Ms. Watson’s osmolality level is slightly elevated to 296 mmol/kg/H2O. This
measurement indicates the concentration of particles found in the blood. A higher
osmolality level indicates a higher concentration of solutes, or electrolytes without a
corresponding water level. Dehydration can be a complication with these types of
procedures, so this level could be significant and should be monitored, especially if
it increases (Nelms, Sucher, Lacey, p137).
According to the laboratory results, Ms. Watson’s hemoglobin and hematocrit
levels are below the normal ranges. Hemoglobin is what delivers oxygen to cells and
hematocrit is the percentage of blood that is composed of red blood cells. The lower
levels post-operative could be partially from any blood loss during the procedure,
but her levels were also slightly low prior to the surgery. This could be significant
because it could indicate that she is not getting enough protein and/or iron from her
diet (Nelms, Sucher, Lacey, p60).
Additionally, Ms. Watson has elevated blood glucose and glycosylated
hemoglobin (A1c) levels, which classify her as a diabetic, coinciding with the
information given in the medical history (Nelms, Sucher, Lacey, p486-487). The
increase in blood glucose in the 24-hour period following her procedure is likely
related to the increased osmolality as well. And lastly, Ms. Watson’s LDL level is
elevated, likely playing a role in her hypertension. The hypertension and diabetes
cause significant abnormal laboratory levels, and should be given proper nutrition
intervention accordingly.
IV. Nutrition Diagnosis
9. Select two nutrition problems and complete the PES statement for each.
Nutrition Problem #1: Elevated glucose levels (NC-2.2) (eNCPT)

PES Statement – Elevated glucose levels related to Type 2 diabetes as
evidenced by a blood glucose level of 151 mg/dL on 11/2and 163 mg/dL on
11/3 and a Hemoglobin A1c level of 6.5 on 11/2.
Nutrition Problem #2: Overweight (NC-3.3) (eNCPT)

PES Statement – Overweight related to excessive intake of saturated fats
and frequent meals eaten outside of home as evidenced by BMI of 27.9 and
elevated LDL levels of 149 mg/dL.
V. Nutrition Intervention
10. The surgeon notes Ms. Watson probably will not resume eating by mouth
for at least 3-5 days. Using ASPEN guidelines, what would be your
recommendation for nutrition support for Ms. Watson?
The ASPEN guidelines for critical care recommend that energy requirements
be assessed using indirect calorimetry or by the use of predictive equations (Nelms,
Sucher, Lacey, p458). I would recommend a transitional feeding method for Ms.
Watson. Making sure to carefully monitor her tolerance and intake/outtake is very
important in these steps. The transition from PN to EN should begin with a minimal
enteral amount at a rate no faster than 30 to 40 mL/hour to establish
gastrointestinal tolerance. The enteral rate can be increased as the parenteral rate
decreases and once the patient was tolerating 75% of her nutrient needs by EN, the
PN can be discontinued. To transition from EN to oral should also be closely
monitored. Clear liquids should be introduced followed by fuller liquids, to easy to
digest solid foods (Mahan, Escott-Stump, Raymond, p321).
11. For each of the PES statements you have written, establish an ideal goal
(based on the signs and symptoms) and an appropriate intervention (based on
the etiology).
PES Statement #1: Elevated glucose levels related to Type 2 diabetes as
evidenced by a blood glucose level of 151 mg/dL on 11/2and 163 mg/dL on 11/3
and a Hemoglobin A1c level of 6.5% on 11/2.

Ideal Goal: Reduce Hemoglobin A1c level to less than 6.0%.

Intervention: Reinforce nutrition-related knowledge and counsel on portion
control, carbohydrate counting methods, and different ways to chose and
prepare at home nutrient-dense, high fiber meals.
PES Statement #2: Overweight related to excessive intake of saturated fats and
frequent meals eaten outside of home as evidenced by BMI of 27.9 and elevated
LDL levels of 149 mg/dL.

Ideal Goal: Decrease LDL level to 130 mg/dL or below and decrease BMI
to below 25.

Intervention: Nutrition counseling on importance of reducing foods high
in saturated fat and collaborate with patients on how to come up with
easy meals to prepare at home, catering to foods that patient likes, while
maintaining proper nutrition guidelines.
VI. Nutrition Monitoring and Evaluation
12. What would be the primary nutrition concerns as Ms. Watson prepares for
rehabilitation after her discharge? Identify nutritional outcomes and outline
specific measures for evaluation.
Diarrhea, flatulence, constipation are all nutrition concerns that Ms. Watson
could experience after she is discharged. It is also important to rule out infections.
Completing stool cultures could be a measure for evaluating the complication.
Dehydration is another potential concern. Fluid status can be assessed by looking at
skin turgor, or just by estimating the adequacy of fluid intake and output. Serum and
urinary measures such as specific gravity, osmolality, BUN and creatinine can assist
in evaluating hydration status. Hyperglycemia is a nutrition concern as well, due to
the diabetes, and should be monitored by HbA1c levels, blood glucose levels, and
based on her 24-hour diet recalls. Ms. Watson’s LDL levels can be monitored and
evaluated by getting laboratory blood work as well as looking at another diet recall.
Her BMI can be measured and monitored by getting up to date anthropometric
measurements at the next appointment (Nelms, Sucher, Lacey, p101-102).
References
International Dietetic & Nutrition Terminology (IDNT): Reference
Manual. Standardized Language for Nutrition Care Process. Academy of
Nutrition and Dietetics, 2014. Retrieved from ncpt.webauthor.com
Mahan, L.K., Escott-Stump, S., Raymond, J.L. Krause’s Food Nutrition & Diet Therapy,
13th ed. Philadelphia, PA: W.B. Saunders Company, 2012
Nelms M. Medical Nutrition Therapy A Case Study Approach 5th ed., Cengage
Learning, 2017.
Nelms M. Sucher K, Lacey, K. Nutrition Therapy and Pathophysiology. 3rd ed.
Cengage Learning, 2016.