2 Subtotal Gastrectomy Nursing Care Plan

Risk for Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis

• Imbalanced Nutrition: Less Than Body Requirements

Risk factors may include

• Restriction of fluids and food
• Change in digestive process/absorption of nutrients

Possibly evidenced by

• Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

• The client will maintain a stable weight/demonstrate progressive weight gain toward the goal with normalization of laboratory values.
• The client will be free of signs of malnutrition.

Nursing Assessment and Rationales

1. Auscultate for resumption of bowel sounds and note passage of flatus.
Peristalsis can be expected to return about the third postoperative day, signaling readiness to resume oral intake.

2. Monitor tolerance to fluid and food intake, noting abdominal distension, and reports of increased pain, cramping, nausea, and vomiting.
Complications of paralytic ileus, obstruction, delayed gastric emptying, and gastric dilation may occur, possibly requiring reinsertion of the NG tube.

3. Note the character and amount of gastric drainage.
Will be bloody for the first 12 hr, and then should clear and turn greenish. Continued or recurrent bleeding suggests complications. A decline in output may reflect the return of GI function.

4. Note admission weight and compare with subsequent readings.
Provides information about the adequacy of dietary intake and determination of nutritional needs.

5. Monitor laboratory studies (Hb and Hct, electrolytes, total protein, prealbumin).
Indicators of fluid and nutritional needs and effectiveness of therapy, and detects developing complications.

Nursing Interventions and Rationales

1. Maintain patency of the NG tube. Notify the physician if the tube becomes dislodged.
Provides rest for the GI tract during the acute postoperative phase until the return of normal function. Note: The physician or surgeon may need to reposition the tube endoscopically to prevent injury to the operative area.

2. Caution patient to limit the intake of ice chips.
Excessive intake of ice produces nausea and can wash out electrolytes via the NG tube.

3. Provide oral hygiene on a regular, frequent basis, including petroleum jelly for lips.
Prevents discomfort of dry mouth and cracked lips caused by fluid restriction and the NG tube.

4. Avoid milk and high-carbohydrate foods in the diet.
May trigger dumping syndrome.

5. Administer IV fluids, TPN, and lipids as indicated.
Meets fluid and nutritional needs until oral intake can be resumed.

6. Progress diet as tolerated, advancing from clear liquid to bland diet with several small feedings.
Usually, the NG tube is clamped for specified periods of time when peristalsis returns to determine tolerance. After the NG tube is removed, intake is advanced gradually to prevent gastric irritation and distension.

7. Administer medications as indicated:

• 7.1. Anticholinergics: atropine, propantheline bromide (Pro-Banthine)
  Controls dumping syndrome, enhancing digestion and absorption of nutrients.

• 7.2. Fat-soluble vitamin supplements, including vitamin B₁₂, calcium
  Removal of the stomach prevents absorption of vitamin B₁₂ (owing to loss of intrinsic factor) and can lead to pernicious anemia. In addition, rapid emptying of the stomach reduces the absorption of calcium.

• 7.3. Iron preparations
  Corrects and prevents iron deficiency anemia.

• 7.4. Protein supplements
  Additional protein may be helpful for tissue repair and healing.

• 7.5. Pancreatic enzymes, bile salts
  Enhances digestive process.

• 7.6. Medium-chain triglycerides (MCT)
  Promotes the absorption of fats and fat-soluble vitamins to prevent malabsorption problems.