Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

Case Study: Patient with a Large Bowel Obstruction

Alyssa Collins
University of Southern Mississippi

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

Part I: Literature Review

Section 1. Abstract
E.S., a patient at St. Marys Hospital, was admitted with a large bowel obstruction. The
patient has a medical history of Type II Diabetes Mellitus and Chronic Obstructive Pulmonary
Disorder. Once admitted, the patient underwent an exploratory laparotomy, sigmoid colectomy,
and Hartmans pouch procedure to treat the large bowel obstruction. Nutrition therapy for a large
bowel obstruction is necessary during the obstruction and post-operatively. Once an obstruction
has been diagnosed, parenteral nutrition support is generally initiated, as the gastrointestinal tract
is non-functioning. Following the procedure, a low fiber diet is generally prescribed to these
patients to allow for bowel rest by avoiding bulking of stools.
In the case of E.S., parenteral nutrition support was initiated a week post-op. The medical
professionals believed the patient would be able to eat normally following the surgery, which
was the reason for delaying initiation of nutrition support. However, the patient developed
dysphagia, which is when speech therapy began evaluating the patient. Nutrition support was
initiated and the patient was able to meet around 80 percent of his estimated needs. During this
time the dietitians monitored the patients tolerance to nutrition support, diet advancement,
intake and output, and nutrition related labs. The patient continued to improve with swallowing
and his appetite slowly improved, therefore a calorie count was initiated in order to discontinue
the parenteral nutrition. The patient advanced to a regular diet and was able to consume 100
percent of his meals. He was discharged to a rehabilitation facility to recover normal daily
functioning.

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

Section 2. Primary Disease

A large bowel obstruction is defined as a blockage in the large intestine. The blockage is
either caused by a mechanical interruption of movement or a pseudo-obstruction, which occurs
when the colon dilates without an anatomic lesion. A mechanical obstruction causes dilation of
the bowel above the blockage. The dilation can cause lowered blood flow to the bowel and
subsequently bowel ischemia. Ischemia can cause bacterial translocation, dehydration, and
electrolyte abnormalities, and even death if not treated. Therefore, prompt treatment is
recommended (Large Bowel (Intestinal) Obstruction, 1995).
There are many causes of mechanical bowel obstructions including diverticulosis,
irritable bowel syndrome, colonic volvulus, hernias, stricture and obstipation, however; the
majority are caused by malignancies (Sawai, 2012). Large bowel obstructions are more common
in the elderly population as they are more susceptible to the causative conditions. Signs and
symptoms include nausea and vomiting, abdominal pain and distention. Symptoms are helpful in
diagnosing the underlying condition that caused the bowel obstruction. If chronic constipation is
an issue, this could mean the causative condition is diverticulitis or a tumor. If there are changes
in stool characteristics, this generally is attributed to carcinoma. Recurrent abdominal pain in the
left lower quadrant usually is indicative of diverticulosis (Large Bowel (Intestinal) Obstruction,
1995).
Proper diagnosis of a large bowel obstruction includes physical assessment. The physical
assessment should include palpation and inspection of the abdomen, inguinal region, and rectum.
A large bowel obstruction is officially diagnosed from an abdominal x-ray, both supine and
upright, and a laparotomy. A CT scan might be used to distinguish between an ileus, partial or
complete obstruction, or obstruction of the small intestine. Laboratory tests that might be taken

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

include a complete blood count, prothrombin time, serum chemistries, and serum lactate if
ischemia is a concern. The primary treatment of a large bowel obstruction is surgical removal of
the obstruction (Sawai, 2012). Other measures include placing a nasogastric tube for suction, IV
fluids and antibiotics. Electrolyte replacement may be needed based on the individuals
laboratory values. Complications associated with large bowel obstructions generally come from
the surgery used to treat the condition. These complications include sepsis and bowel
perforations (Large Bowel (Intestinal) Obstruction, 1995).
Section 3. Secondary Diseases
Type II Diabetes Mellitus is a condition related to insulin resistance. Type II diabetes
accounts for 95 percent of all diagnosed cases of diabetes. This disease is generally diagnosed
later in life. Risk factors for type II diabetes include obesity, physical inactivity, poor diet, and a
family history of the disease. Medications are generally prescribed for the disease to prevent
rapid changes in serum glucose levels. Medical Nutrition Therapy for type II diabetes includes
educating patients on carbohydrate counting, the differences between complex and simple
carbohydrates, how physical activity increases insulin productivity, and monitoring blood
glucose levels. Uncontrolled diabetes can lead to a plethora of problems such as renal
insufficiency, vision impairment, and amputations (Mahan & Raymond, 2012).
Chronic Obstructive Pulmonary Disease (COPD) is a general term that includes both
emphysema and chronic bronchitis. Emphysema occurs when there is chronic damage to the
alveoli. Bronchitis is characterized by inflammation of the bronchi. COPD increases the amount
of calories needed, due to an increase in energy needed to breath. In addition, protein needs are
increased to around 1.2 to 1.7 g/kg of body weight for proper strength of the lung muscles, and to
increase immune function. Fluid status must also be monitored for proper lung function (Mahan

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

& Raymond, 2012). Medical Nutrition Therapy is specific to the patients condition and their
assessed needs.
Section 4. Evidence Based Nutrition Recommendations
Nutrition therapy is not the primary treatment of a large bowel obstruction. Treatment
typically involves surgical removal of the obstruction or colonic stent placement. However,
nutrition is vital for the prevention of a large bowel obstruction, and does have a role in the
treatment process.
A general, healthful diet that meets the recommended daily allowances is recommended
for patients who are prone to large bowel obstructions. Carbohydrates should account for 45 to
65 percent of calories, protein should account for ten to 35 percent of calories and fat should
account for 20 to 35 percent of total calories (Mahan & Raymond, 2012). Increased intake of
fruits, vegetables and whole grains is recommended to increase essential vitamin and mineral
consumption that can prevent against the causative agents of large bowel obstructions. Dietary
changes are only recommended after a patient has been diagnosed with a large bowel
obstruction.
Due to the fact that large bowel obstructions are caused by a multitude of conditions
including cancer, diverticulitis, and obstipation, there are different nutrition therapies to prevent
these disorders. One of the main dietary recommendations for prevention of these causative
conditions is a high fiber diet. Including fiber in the diet has been found to be a cost-effective
and well-tolerated treatment for these conditions (Wisten & Messner, 2005). A position paper
published in the Journal of the Academy of Nutrition and Dietetics states that a diet containing
20-35 g of fiber a day lowers the risk for developing colon cancer, diverticulosis and prevents
constipation (Marlett, McBurney, & Slavin, 2002). However, the Evidence Analysis Library

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

produced mixed results on fiber and the gastrointestinal tract that increasing fiber in fact
increased symptoms in patients with ulcerative colitis, and decreased symptoms for patients with
diverticulitis. Additionally, other sources have produced conflicting conclusions; that fiber in
fact causes obstructions. According to Krauses Food and the Nutrition Care Process,
obstructions may be caused when fibrous foods are not fully chewed and therefore are not small
enough to pass through the abnormally structured intestines (Mahan & Raymond, 2012).
Therefore dietary recommendations on fiber intake for patients with a large bowel obstruction
vary. Patients who are prone to bowel obstructions should be advised to limit fiber intake and
chew fibrous foods thoroughly. Patients with generally normal gastrointestinal (GI) function may
increase fiber intake to prevent large bowel obstructions.
Treatment of a large bowel obstruction through nutrition varies depending on the medical
treatment. Large bowel obstructions often cause abdominal pain and distention, which causes a
decrease in appetite, avoidance of certain foods and therefore a lowered energy intake. It is
recommended that a patient not eat 12 hours before a surgery. In many cases, patients are given
parenteral nutrition (TPN) to provide essential nutrients. Parenteral nutrition is recommended
over enteral nutrition due to the malfunction of the gut associated with a large bowel obstruction.
In fact, pre- and postoperative nutrition support has been found to reduce mortality and
morbidity related to surgery in addition to the underlying condition (Mullen, Buzby, Matthews,
Smale, & Rosato, 1980). According to evidence published by the Cochrane library, pre-operative
parenteral nutrition support decreased post-operative complications for patients undergoing a
gastrointestinal surgery (Burden, S., Todd, C., Hill, J., & Lal, S., 2012). Therefore, it is
commonplace for a patient to receive parenteral nutrition for a GI surgery. After a successful
gastrointestinal surgery, a common nutrition prescription is a low fiber diet. This allows for

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

bowel movements to be slowed in the gastrointestinal tract, which provides the bowel with
increased healing time (Mahan & Raymond, 2012).
If not treated quickly, large bowel obstructions can have significant health outcomes,
even death. In a study conducted on patients with large bowel obstructions caused by carcinoma,
patients with removable tumors had an increased mortality rate if a trainee surgeon, compared to
a fully trained surgeon, performed the surgery (Fielding, Stewart-Brown, & Blesovsky, 1979).
Therefore, it is imperative that a patient be treated immediately once diagnosed by a skilled
professional. Once the patient is diagnosed, the patient may receive parenteral nutrition to
prevent malnutrition during treatment. After treatment, a patient may return to a regular diet as
medically able. In some cases, patients will never regain full function of the gastrointestinal tract
and will discharge home on parenteral nutrition. The dietary recommendations for discharge will
depend highly on the cause of the large bowel obstruction, and the course of treatment.
Nutrition counseling by a registered dietitian is helpful for patients who have
gastrointestinal problems such as a large bowel obstruction. A patient might not understand the
need for parenteral nutrition, or understand the role of fiber with their condition. It is important
that the registered dietitian explain the aspects of the diet to the patient specifically tailored to
their condition, especially in regards to their fiber needs. More research needs to be conducted on
specific nutrition therapy for patients with large bowel obstruction to make evidence-based
recommendations.

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

Part II: Nutrition Care Process

Section 1. Patient Information
E.S., 78 year-old white, male
Height: 60
Weight: 116.4 kg (256 lb)
Body Mass Index (BMI): 34.8
Ideal Body Weight (IBW): 81 kg (178 lb), currently 144% of IBW
Social history: Married with children
Past Medical History: Type II Diabetes Mellitus, hypertension, hyperlipidemia, diverticulitis,
basal cell carcinoma, COPD
Family History: N/A
Psychological History: Depression
Admitted: 11/1
Discharged: 11/18
History of present illness: The patient was admitted one week prior in a nearby hospital with
abdominal distention, abdominal discomfort and nausea. He was treated for an ileus and was
discharged home on 10/26. Following the discharge the distention increased again; he had not
been passing flatus or had a bowel movement. He denies weight loss. Due to the pain, he was
unable to eat much; this lead to a severe hypoglycemic episode with a seizure. He was admitted
again, his serum glucose level was found to be 22. The patient had a CT scan, which found a
distended bowel, worsening colon, structuring in the sigmoid region, and distal pneumatosis. At
admission the patient stated he was feeling a little rough but not too bad, reports some pain and
nausea.
Admitting diagnosis: Distal large bowel obstruction with associated distal pneumatosis coli, the
cause of the obstruction is not certain at this point. Insulin-dependent Type II diabetes mellitus,
on multiple oral agents at home, as well as a large dose of Lantus daily, presenting with severe
hypoglycemia with associated seizure. Chronic COPD with chronic hypoxemic respiratory
failure, he is on 4 L of oxygen by nasal cannula continuously at home.
Diagnoses during admission: Large bowel obstruction found due to adenocarcinoma of colon on
11/4.

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

Section 2. Assessment
Food/Nutrition-Related History (FH) this subsection should discuss food and nutrient intake, medication/herbal supplement
intake (including rationale behind usage and drug-nutrient interactions), knowledge/belief/attitudes and behaviors, food and supply
availability, physical activity, and nutrition quality of life, as applicable
List Specific Nutrition
Describe the actual information gathered from the
Nutrition Assessment Terms
Assessment Term (e.g. Oral
patient/patients family/medical record
fluids, food allergies, etc.)
Energy Intake
Fluid/Beverage Intake
Food Intake
Breastmilk/infant formula intake
Enteral nutrition intake
Parenteral nutrition intake
Alcohol intake
Bioactive substance intake
Caffeine intake
Fat and cholesterol intake
Protein intake
Carbohydrate intake
Fiber intake
Micronutrient intake
Vitamin intake
Mineral intake
Diet Order
Admission diet order:
NPO at admission due to large bowel obstruction and need for
surgery
Diet Experience
Eating Environment
Enteral and parenteral
administration
MedicationsInclude the use for
each medication as it pertains to
the patient/clients medical
condition(s)
Complementary/Alternative
medicine
Food and nutrition
knowledge/skill
Beliefs and attitudes
Adherence
Avoidance behavior
Binging and purging behavior
Mealtime behavior
Social network
Food/nutrition program
participation
Safe food/meal availability
Safe water availability
Food and nutrition-related
supplies available
Breastfeeding
Nutrition-related ADLs and
IADLs
Physical activity

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

10

Factors affecting access to

physical activity
Nutrition quality of life
Anthropometric Measurements (AD)Calculate as needed this subsection should discuss height, weight, body mass index,
growth pattern indices/percentile ranks, and weight history, as applicable
Describe the information
Provide calculations and
List Specific Nutrition
gathered from the
interpretation (e.g. Obese,
Nutrition Assessment Terms
Assessment Term (e.g. Oral
patient/patients
significant weight loss, etc.)
fluids, food allergies, etc.)
family/medical record
of anthropometrics
Body
Height:
60
Height in meters:
composition/growth/weight
Weight:
256 lb, 116.4 kg
72 in x 0.0254 = 1.8288
history
Weight history:
Stable prior to admission
BMI:
34.8
Weight in kg:
Ideal body weight (IBW):
178 lb, 81 kg
256/2.2=116.4
Percent IBW:
144% IBW
Adjusted body weight:
90 kg
BMI calculation:
116.4/(1.82882)=34.8, Obese
class I
Ideal body weight:
106 + (6 x 12) = 178 lb
178 / 2.2 = 81 kg
Percent IBW:
116.4 kg/ 81 kg = 144%
Adjusted body weight:
((116.4- 81) x 0.25) + 81 =
90 kg
Biochemical Data, Medical Tests, and Procedures (BD)Indicate if abnormal this subsection should discuss relevant
nutrition-related laboratory data and tests, as applicable
Describe the
Describe the cause of the abnormal lab
List Specific Nutrition
information gathered
values, specifically as it relates to the
Assessment Term
Nutrition Assessment Terms
from the
patients medical condition(s)
(e.g. Oral fluids, food
patient/patients
allergies, etc.)
family/medical record
Acid-base balance
Electrolyte and renal profile
Potassium (K)
See chart below
See chart below
Sodium (Na)
Essential fatty acid profile
Gastrointestinal profile
Glucose/endocrine profile
Glucose POCT:
39-298
Type II diabetes, stress, TPN
Inflammatory profile
Lipid profile
Metabolic rate profile
Mineral profile
Magnesium (Mg)
See chart below
See chart below
Phosphorus (P)
Calcium (Ca)
Nutritional Anemia profile
Protein profile
Urine profile
Vitamin profile
Carbohydrate metabolism profile
Fatty acid profile
Nutrition-Focus Physical Findings (PD) this subsection should discuss findings from an evaluation of body systems, muscle and

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

11

subcutaneous fat wasting, oral health, suck/swallow/breathe ability, appetite, and affect, as applicable
Describe the
List Specific Nutrition
information gathered
Provide a narrative that explains your
Assessment Term
Nutrition Assessment Terms
from the
findings from a NFPE that you conducted
(e.g. Oral fluids, food
patient/patients
on your patient/client
allergies, etc.)
family/medical record
Nutrition-focused physical
Temporalis muscle,
After performing the NFPA by both
findings
orbital region,
observing the patient and by examining
clavicle, shoulder,
certain areas through palpation, the patient
biceps
was found to have a well defined
temporalis muscle, bulged fat pads under
the orbital region, a distended stomach,
and rounded arms and shoulders with
ample tissue. The patient was found to
have no protein-calorie malnutrition
evident.
Client History (CH) this subsection should discuss current and past information related to personal, medical, family, and social
history, as applicable
List Specific Nutrition
Describe the information gathered from the patient/patients
Nutrition Assessment Terms
Assessment Term (e.g. Oral
family/medical record
fluids, food allergies, etc.)
Personal data
Social status:
Married, with children
Psychological status:
Depression
Patient/client OR family
nutrition-oriented medical
history
Treatments/therapy
Social history
Comparative Standards (CS)--Calculate as needed this subsection should provide estimations of the patients nutritional
requirements with identification of methods used for calculations. At a minimum, calculations should include kcal, protein, and
fluid requirements. Note, the intern should include an evidence-based rationale behind which predictive equation for calories is
used. Requirements for individual substrates (carbohydrates, saturated fat, etc) and/or individual nutrients (potassium, phosphorus,
sodium, etc.) can be included, as applicable.
Indicate the Comparative
Provide a referenced
Nutrition Assessment Terms
Calculate, as needed
Standard Used
rationale for the
Comparative Standard Used
Estimated energy needs
2070-2250 kcal
(23-25 kcal/kg adjusted
(Dietary Reference Intakes
weight)
(DRIs): Estimated Average
Requirements, n.d.)
Estimated fat needs
450-788 kcal
20-35% kcal
(Dietary Reference Intakes
50-88 g
(DRIs): Estimated Average
Requirements, n.d.)
Estimated protein needs
116-140 g
1.0-1.2 g/kg actual body
(Dietary Reference Intakes
weight
(DRIs): Estimated Average
Requirements, n.d.)
Estimated carbohydrate needs
1013-1463 kcal
45-65% kcal
(Dietary Reference Intakes
253-366 g
(DRIs): Estimated Average
Requirements, n.d.)
Estimated fiber needs
20-35 g/day
20-35 g/day
(Dietary Reference Intakes
(DRIs): Estimated Average
Requirements, n.d.)
Estimated fluid needs
2070-2250 kcal
1 ml/kcal
(Dietary Reference Intakes
(DRIs): Estimated Average
Requirements, n.d.)
Estimated vitamin needs

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

Estimated mineral needs
Recommended body
weight/body mass index/growth

IBW: 81 kg

Hamwi equation for men

12

(Ideal Body Weight (IBW),

Growth Charts, and Body
Mass, 2015)

Section 3. Malnutrition Identification

The patient does not meet malnutrition criteria. This was determined by performing a
Nutrition Focused Physical Assessment (NFPA), using both inspection and palpation. The
assessment determined that they patient has a well-defined temporalis muscle, bulged fat pads of
the orbital region, and rounded arms and shoulders with ample tissue. The abdominal area was
distended and some general edema was noted.

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

Section 4. Medical Nutrition Therapy and Diet Orders

Day:
11/1-11/8
11/9
11/10

11/11

11/12

Diet order:
NPO
Dysphagia II, Thin
liquids
Dysphagia II, Thin
liquids

Supplements:
-

Estimated intake:
0%
5% PO

25% PO

TPN: 100 grams Dex

and 75 grams AA goal
rate 42 ml/hr.
Dysphagia II, Thin
liquids
TPN: 200 grams Dex
and 125 grams AA at
63 ml/hr
Dysphagia III, Thin
liquids

11/14

TPN: 300 grams

DEX, 125 grams AA
goal rate 83 ml/hr to
provide 1520 kcals, 4.
TPN day 2 if Trig <
400 add 50 grams
20% lipids to TPN
daily for 500
additional calories.
Totals kcal and
protein: 2020 kcals,
125 grams protein
Regular diet

11/15

TPN at goal
Regular diet

30-75% PO

30-75% PO

Boost Glucose
Control TID

85% PO

Boost Glucose
Control TID

95% PO

Boost Glucose
Control TID

100% PO

TPN at goal
11/16

Calorie count initiated

Regular diet

13

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

14

Section 5. Anthropometric and Biochemical Trends

Weight trends:

Weight (kg)
118
116
114
112
110
Weight (kg)

108
106
104
102

The trends seen in weight appear abnormal at first glance. However, the decrease in
weight from November first to November fourth followed the surgery for the large bowel
obstruction. The patient had abdominal distention and minor edema noted, therefore this weight
followed the removal of the obstruction and a decrease in inflammation. Weight appeared to
trend upwards after November seventh due to the parenteral nutrition. This increase in weight
can be attributed to fluid accumulation.

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

Na
K
CO2
BUN
Creatinine

GFR
Glucose
Calcium
Mg
P
Albumin

15

Lab value trends (Dates in November; Arrows indicate which direction results are out of normal range):
2
3
4
5
7
8
9
10
11
12
13
14
15
16
17
137 134 133 134 138 140 144 146 147 143 143
137 139 140 140
()
()
()
()
()
4.1
3.9
3.5
3.3
2.3
2.2
2.7
2.6
2.9
2.5
2.8
3.5
2.5
2.8
2.7
()
()
()
()
()
()
()
()
()
()
()
35
28
27
26
29
35
36
39
39
40
42
39
42
40
39
()
()
()
()
()
()
()
()
()
()
()
17
27
40
22
12
10
8
7
10
15
21
21
20
23
19
()
()
()
0.75 1.09 1.54 0.81 0.59 0.62 0.61 0.67 0.66 0.72 0.59
0.67 0.59 0.64 0.65
()
()
()
()
()
()
()
()
()
()
88
65
43
85
97
95
96
93
93
89
97
92
97
93
93
()
39
200 143 139 154 198 234 196 210 298 192
237 163 176 86
()
()
()
()
()
()
()
()
()
()
()
()
()
()
8.7
7.7
7.6
7.8
7.7
7.9
7.8
7.9
7.9
8.0
8.0
7.9
8.1
8.0
8.0
()
()
()
()
()
()
()
()
()
()
()
()
()
()
1.8
1.7
1.5
2.0
1.7
1.8
1.7
1.9
1.7
1.7
1.7
3.3
2.4
1.9
1.5
1.6
2
2.4
1.7
2.1
2.4
3.0
2.7
2.3
2.7
()
()
()
()
()
()
()
()
()
3.4
2.2
1.9
1.9
1.9
2.3
()
()
()
()
()

Many of the abnormalities above can be attributed to the parenteral nutrition and the
patients condition. Serum glucose levels will rise in stressed patients. This patient is also
diabetic, which describes the high levels of glucose throughout hospitalization. Glucose was
being treated through medications, however there were interactions between the parenteral
nutrition that was being administered and the PO intake. Electrolyte abnormalities are related to
the fluid status of the patient and the parenteral nutrition formula.

18
139
2.9
()
42
()
15
0.69
()
91
152
()
8.1
()
-

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

16

Section 6. Nutrition Diagnoses

1. Altered gastrointestinal function related to alteration in gastrointestinal tract structure
from obstruction as evidenced by endoscopic examination results, abdominal distention
and nausea.
2. Inadequate energy intake related to decreased ability to consume sufficient energy as
evidenced by estimated energy intake from diet less than needs based on estimated
resting metabolic rate.
3. Inconsistent carbohydrate intake related to physiological causes requiring careful timing
and consistency in the amount of carbohydrate, diabetes mellitus, as evidenced by severe
hypoglycemia, blood glucose level of 22.
Section 7. Nutrition Interventions
Medical interventions:
The patient underwent an exploratory laparotomy, sigmoid colectomy, and Hartmans
pouch procedure on 11/2 as treatment for the large bowel obstruction. The patient was intubated
for the procedure and transported to the intensive care unit following the surgery. The patient
was extubated on 11/4.
Nutrition Interventions:
Nutrition
Intervention
Terminology

Meals and
Snacks

List Specific
Nutrition
Intervention
Term(s)
Texturemodified diet
General
healthful diet

Describe the actual

intervention that was
completed

As the patient was

weaned from
parenteral nutrition,
the patient advanced
from NPO to a

Discuss the
rationale/justification for
recommendations,
including references, as
appropriate
The patient worked with
speech language
pathologists (SLP) to
determine swallowing
capability. This is

Describe if this was the most

appropriate intervention
based on the literature. If
not, discuss what should
have been done differently
Aspiration pneumonia is a
common issue when patients
develop dysphagia. The
protocol followed was
appropriate due to the

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

17

dysphagia II diet to a
dysphagia III diet to
a regular diet, as
medically able.

important for prevention

of aspiration and
subsequent pneumonia.

patients condition.
However, the patient could
have benefited from
advancing to a diabetic diet,
rather than a regular diet.

TPN was initiated

and slowly increased
to meet at least 80
percent of the
patients needs.

TPN should be
administered at a low
concentration on the first
and second day to avoid
re-feeding syndrome. This
patient had been NPO for
over a week, so it was
important to start at a
lower concentration to
avoid electrolyte
imbalance.

Research shows that

nutrition support is more
effective when initiated early
post-operatively (Mullen,
Buzby, Matthews, Smale, &
Rosato, 1980). Earlier
initiation of TPN may have
decreased the patients
length of stay and would
have provided nutrition
during the week the patient
needed to remain NPO.

Boost Glucose Control is a

carbohydrate-controlled
supplement, therefore is a
diabetic friendly formula.
It provides 190 calories
and 16 grams of protein.
This is helpful to feed

As the patient was slowly

regaining appetite and the
ability to swallow, a
nutrition supplement was a
helpful source to supply
protein and calories. The
supplement was low in

Enteral
Nutrition
Parenteral
Nutrition/IV
Fluids

Composition
Concentration
Rate
Schedule

TPN day 1:
100 grams Dex and
75 grams AA goal
rate 42 ml/hr.
TPN day 2:
200 grams Dex and
125 grams AA at 63
ml/hr

Medical Food
Supplement
Therapy

Commercial
beverage
supplement

TPN day 3:
300 grams DEX, 125
grams AA goal rate
83 ml/hr to provide
1520 kcals, 4. TPN
day 2 if Trig < 400
add 50 grams 20%
lipids to TPN daily
for 500 additional
calories. Totals kcal
and protein: 2020
kcals, 125 grams
protein
When the patients
intakes were low,
Boost Glucose
Control was given to
the patient three
times daily with
meals.

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

18

patients who are not

consuming enough energy.

carbohydrates, which was

helpful for the patients
history of diabetes, as well
as decreasing the respiratory
quotient, which helped with
the underlying COPD.

The patient needed to

be seated upright to
be given food for
meals and for
swallow evaluations.

The patient was seated

upright to avoid aspiration.
While the patient was
transitioning to being
independent, oral care was
administered every 6
hours.

This intervention was

appropriate for the patient to
regain swallowing strength.

Vitamin and
Mineral
Supplement
Therapy
Bioactive
Substance
Management
Feeding
Assistance

Feeding
Position
Mouth care

Manage
Feeding
Environment

Distractions

As the patient
worked with the SLP,
distractions were
minimized during
meal times by having
one-on-one meal
times with the SLP
and by turning off the
television and
focusing solely on
the meal.

This allowed for the

patient to focusing on
swallowing, and allowed
for the SLP to determine if
the muscles needed to
swallow were functioning
properly.

This intervention was

appropriate for the patient to
regain swallowing strength.

Nutrition
Related
Medication
Management

Prescription
medications

To treat the patients

type two diabetes, 14
units of Insulin
Glargine and zero to
ten units of Insulin
Lispro were
administered daily.

These medications were

all prescribed by the
attending, and were given
based on the patients
daily needs.

These medications were

appropriate for the patients
conditions.

The patient was

given small amounts

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

of dextrose in normal
saline at 30-50 ml/hr
when on the
ventilator. Once the
TPN was started, this
was stopped, to
prevent excessive
carbohydrate
administration.
The patient was
prescribed and given
Pepcid as an antacid.
The patient was
given K-DUR to
increase potassium
levels in the body.
The patient was
prescribed and given
Zocor, Prinivil, and
Zetia for high
cholesterol and high
blood pressure.
Aldactone was
prescribed as a
diuretic for high
blood pressure.
Nutrition
EducationContent
Nutrition
EducationApplication
Nutrition
CounselingTheoretical
Nutrition
CounselingStrategies

19

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

20

Collaboration
and Referral of
Nutrition Care
Discharge and
Transfer of
Nutrition Care

Discharge
and transfer
to other
providers

The plan of care was

to discharge the
patient to a skilled
nursing facility in
Moab, Utah for
rehab.

This hospital is near the

patients home and will
provide extensive
rehabilitation for the
patient.

This was appropriate for the

patient. He wanted to be
closer to home, but needed
to go to rehab in order to
return to normal daily
functioning following
hospitalization.

Section 8. Monitoring and Evaluation

As the patient remained in the intensive care unit, the dietitian monitored the need for
nutrition support. This was completed in daily rounds with the attending and other medical
professionals. Once the need for nutrition support was assessed, the dietitian calculated the
patients needs, and the TPN was administered.
Once the TPN started infusing, the dietitians monitored the patient for tolerance to
nutrition support, diet advancement, gastrointestinal tolerance, intake and output, weight, and
nutrition related labs. The patient was classified severely compromised due to the patients
diagnosis, extended NPO status, and energy intake. Due to this classification, the patient was
monitored every three to five days. The dietitian monitored the patient by accessing the patients
medical record and assessing the lab results, as well as discussing the patient with other medical
professionals to determine the best course of care. The dietitian continuously examined the
patient to assess for protein-calorie malnutrition, edema, and TPN tolerance. Once the patient
started eating food by mouth, the dietitians, to assess when the TPN could be discontinued,
initiated a calorie count. Follow-ups by the dietitians were performed a total of six times during
the patients hospital stay.

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

21

Once discharged, the plan of care was to send the patient to Moab Regional Hospital for
rehabilitation. The hospital will help the patient to regain strength and become fully functional.
No follow-up on the patient will be conducted once the patient is discharged from St. Marys
Hospital.
Section 9. Conclusion
A large bowel obstruction has a significant impact on a patients nutritional status. Large
bowel obstructions cause abdominal pain, which decreases appetite and energy intake. This was
indeed a problem faced with this patient, both before and after the procedures. The need for
nutrition support is another issue commonly faced with these patients. It is vital to preserve gut
function, however a patient may need parenteral nutrition support before and after surgery to
prevent malnutrition. As seen in this case, parenteral nutrition support was not administered
initially, as the medical professionals believed the patient would regain normal swallowing
function post-operatively. However, the patient experienced dysphagia and had to work with
speech pathologists to regain normal swallowing abilities. During this time, the patients
electrolyte levels, weight status, gut function and intake/output were monitored to assess when
the patient would be able to tolerate a regular diet again. More research needs to be conducted on
medical nutrition therapy for evidence-based recommendations regarding administration of TPN,
and diets for prevention and treatment of large bowel obstructions.

Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

22

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Running head: CASE STUDY: PATIENT WITH A LARGE BOWEL OBSTRUCTION

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