Surgical Case Study

Kristine Myers
Dietetic Intern

Introduction:
Patients Initials N.G.
Primary problem Fungating cecal mass
Other medical conditions Hypertension
Height 163 cm; 64 in
Weight 59 kg; 130 lbs
Age 78
Sex female
Reason patient was chosen Open and talkative surgical patient . Worked with her daily
on diet advancement.
Date the study began and ended March 22 - 27th
Focus of this study Colon resection and diet following

Social History:
Occupation retired
Marital status married
Health insurance Medicare
Family responsibilities takes care of cooking, cleaning, self-grooming, grocery
shopping
Home environment lives with husband, former smoker for 20 years, quit smoking in
2003, consumes 1-2 gin drinks daily

Normal anatomy and physiology:

The lower gastrointestinal (GI) tract starts with the small intestine . The small
intestine is made up of three parts: the duodenum, jejunum and ileum . Each part has
different digestion, absorption and secretion functions . A majority of food and nutrients
are digested and absorbed in the small intestine . Between digestive enzymes and
peristalsis, food is propelled through the small intestine or absorbed into the
bloodstream. The food that is propelled through the small intestine moves to the large
intestine. In the large intestine water and any other nutrients such as vitamin K, vitamin
B-12, riboflavin and thiamine, are absorbed and the remaining matter moves to the
rectum as waste. From the rectum, waste is excreted from the body. The main functions
of the large intestine are storing waste, reabsorbing water and nutrients and maintaining
fluid balance. Each section of the lower GI is important to maintain homeostasis within
the body.1

Past medical history:

Acute ischemic VBA thalamic stroke
Essential hypertension
Hypercholesterolemia
Skin cancer
Lung nodule discovered in 2014, chest x-ray repeated with unchanging results

Present medical status and treatment:

Theoretical discussion of disease condition
With the aging process, physicians advise routine colonoscopies . Regular
screenings are recommended after the age of 50 and sooner if other factors make
someone more likely to develop colon cancer. During a colonoscopy doctors look at the
inner lining of the patients large intestine . They are looking for ulcers, polyps, tumors,
bleeding or areas of inflammation. The doctor can take tissue samples during the
colonoscopy to check for cancerous or precancerous cells . The doctor is also able to
remove abnormal growths. Scheduling a colonoscopy can prevent abnormal growths
from developing into cancer.
Researchers are not positive what causes colon polyps to develop, but it is
suggested that age and family history play a role . Studies have shown those with
inflammatory bowel diseases like Colitis and Crohn's have a higher chance of polyp
formation, as well as individuals who are overweight or smoke . Colon polyps often
develop without causing an individual any symptoms, which is why doctors advise
regular colonoscopy appointments. If an individual is experiencing any rectal bleeding or
bloody stools it may be the result of a colon polyp . Polyps found during a colonoscopy
are biopsied to test for the development of cancer cells . If found soon enough polyps
can be removed before they grow into larger masses and before they develop into
cancer or metastasize to other parts of the body. Some individuals are not as fortunate
to have their colon abnormalities discovered early on . As abnormalities grow and cells
continue to develop, the polyp may be referred to as a cecal mass .2
Usual treatment of condition
There are two types of polyps found in the large intestine . One type, the
hyperplastic polyp carries little risk of developing into cancer . If it is biopsied and results
present no sign of cancerous or precancerous cells, the doctor may present the patient
with an option to monitor the mass. This is assuming the patient has no digestive
symptoms such as rectal bleeding, weight loss or abdominal pain . The other type is
known as adenomas polyps. These are considered precancerous polyps and likely if left
untouched will develop into cancer. In the case of adenomas polyps, removal is
necessary. Most colon polyps can be removed during a colonoscopy using special tools
to lift them from the healthy tissue. If the doctor cannot remove it during the
colonoscopy, surgery is required. Surgeries to remove polyps are usually due to the
large size or the type of cells that make up the polyp .2

When the removal of a polyp or cecal mass cannot be done during a

colonoscopy, surgery is scheduled. Depending on the size of the mass a colon
resection may be performed. Prior to this operation a patient would be given a NPO diet
order so that their gastrointestinal tract is cleaned out . During the procedure the
surgeon will remove the mass by cutting out all areas of the colon or large intestine that
the mass is covering. The surgeon will then piece the colon back together with what
remains. Due to the colon being a vital part of the GI tract patients are required to take
baby steps back to eating.
When they are awake and alert patients will be issued a clear liquid diet .
Tolerating clear liquids will prove to the doctor that the patient can move to a full liquid
diet. Tolerating full liquids is determined when the patient is able to pass gas and have
bowel movements. At that time the patient can begin with soft, easy to digest, low fiber
foods. A gradual progression is made so that the colon has time to heal and each
progression is a stepping-stone back to a normal healthy diet .3
Patients symptoms upon admission leading to diagnosis and explain etiology
Patient N.G. had a colonoscopy in February of 2016 where doctors noted she
had a non-obstructing 4 cm x 2 cm friable fungating mass in her cecum . Biopsies
were performed showing the mass was consistent with high-grade dysplasia .
When N.G. arrived at the hospital as an inpatient she stated she had
approximately 30 pounds of unintended weight loss over the last couple months .
She complained of diarrhea but denied nausea and vomiting . She had no
complaint of trouble eating and had not noticed any blood in her stools .
It is possible N.G. experienced weight loss due to the cecal mass . She may have
been having trouble digesting her food, which would explain the diarrhea as well .
It is likely that N.G. unknowingly had a decreased appetite from the digestion
issues she was experiencing.
Laboratory findings and interpretation
3/23

3/24

3/26

3/27

Trends

Normal Range

Hemoglobin

10.7 L

11.4 L

11.4 L

12 L

Trending up

12.0 - 15.5

Hematocrit

30.3 L

31.9 L

32.3 L

33 L

Trending up

34.0 - 44.5

Sodium

132

136

135

132

WNL

132 - 143

Potassium

4.7

4.3

3.8

3.9

WNL

3.5 - 5.0

Glucose

115 H

95

84

90

BUN

5L

6L

Trending back up

6 - 20

Creatinine

.86

.82

.79

.86

WNL

0.7 - 1.2

70 - 100

Magnesium

1.5 L

Phosphorus

3.2

2.0
-

1.7 - 2.6
WNL

2.5 - 4.5

Patient N.G.s labs appeared fairly adequate. Hemoglobin and Hematocrit

were the only lab values of concern upon discharge . They were trending up in
the correct direction though. The low Hemoglobin and Hematocrit could have
been due to fluid overload or a poor diet following surgery .4 According to the
progress notes and nursing documentation N .G. did not have any edema. From
the information gathered, I would guess the low lab values are diet related . As
N.G.s diet was advanced, her labs began trending back to normal limits . N.G.
had a small dip in her BUN level, but that was corrected prior to discharge .
Everything else appeared to be within normal limits .
Medication
Famotidine (Pepcid) 20 mg oral tab
o

Ciprofloxacin 500 mg oral tab

o

Taken BID as needed for pain

Acetaminophen (Tylenol) 325 mg oral tab

o

Taken once a day for pain

Naproxen Sodium (Aleve) 220 mg oral tab

o

Taken once a day for Hypertension

Aspirin 325 mg oral tab

o

Taken once a day for high blood pressure

Amlodipine Besylate 5 mg oral tab

o

Diuretic taken once a day for Hypertension

Lisinopril 20 mg oral tab

o

Take every 12 hours for 3 days for infection

Hydrochlorothiazide 25 mg oral tab

o

Taken every 12 hours for decreased gastric secretions

Taken every 6 hours as needed for pain

Zolpidem Tartrate (Ambien) 5 mg oral tab

o

Taken once a day as needed for insomnia

Observable physical and psychological changes in patient

Physiologically N.G. responded normally to the procedure performed . Her pain
was tolerated using medication and her doctors advanced her diet slowly in order
to give her GI tract time to heal. Her hospital stay was within an expected length
of time and her diet progressed as expected.
Psychologically N.G. was quite agitated. She was not happy with the progression
of her diet. N.G. expressed during each visit how much she disliked the clear
liquid and full liquid diet orders. N.G. was frustrated with not being able to
consume solid foods for several days . The patient could not wait to pass gas and
have a bowel movement so she could have normal food .
Treatment
After N.G.s colonoscopy when the mass was found, her doctor made a follow up
appointment to discuss treatment options. He suggested a colon resection would be the
only way to remove the mass and followed up with the complications and risk that come
with that type of surgery. N.G. agreed to the colon resection. A R. Hemicolectomy was
scheduled for March 25th, 2016.
A R. Hemicolectomy is the removal of the right side of the colon . The right side
includes the caecum, ascending colon, and part of the transverse colon . Removing this
large of an area is not due to the size of the mass but rather the way blood is supplied
to the colon. Although with this area of the colon being removed, the mass will be fully
withdrawn from N.G. When the surgeon is done cutting out the necessary portion of the
colon, N.G.s small intestine was sewn or stapled to the new beginning of the large
intestine. This completed the surgery and the patient was taken to the recovery room .

Medical Nutrition Therapy:

Nutrition history (usual eating pattern, past diets, time and place of meals, prep of food)
Patient N.G. prepared her own meals prior to her colectomy. She commonly has
three meals per day with no added snacking. N.G. does not follow a particular diet, but
stated she does her best to eat healthy . Meal times vary, as she is retired, but most
often meals are prepared and eaten at home . Occasionally N.G. orders take out, such
as pizza for dinner. The patient has no known allergies and does not avoid any specific
food groups.
24-hour recall and calculations

Meal:

Food:

Breakfast Omelet (3 medium eggs)

Orange Juice 8 oz

Lunch

Ham sandwich w/ mayo

1% milk 8 oz

Dinner

Steak 6 oz
Medium baked potato w/ butter & sour cream
Peas ( cup)
Gin (1 oz) and tonic

During the time of the 24-hour recall, N.G. was on a liquid diet at the hospital.
The recall above is a normal day for N.G. prior to admission at the hospital. She
shared that she is not a snacker and hasnt been enjoying sweets . The above recall
was just under 1600 calories and close to 100 grams of protein . Her diet consisted of
very few whole grains and fiber. She had adequate dairy intake, but could benefit from a
diet higher in fruits and vegetables. N.G.s fat intake is much higher than recommended .
According to the 24-hour recall 47% of calories consumed are from fat, greatly
exceeding the recommended 20 - 35%. With the three small meals N.G. consumes, she
still exceeds both her recommended protein and fat intake .
N.G. should consider eliminating her daily gin and tonic . She stated she has 1
2 drinks per night. Consuming alcohol on a regular basis provides the body with empty
calories and also causes damage to several of the bodys organs including the liver and
brain. Cutting back her alcohol consumption and increasing her fruit and vegetable
consumption would provide N.G. a healthy and nutritious diet.
Taking into consideration N.G.s recent weight loss and being status post surgery,
she should consume an estimate of 1475 1770 calories per day . The 24-hour recall
provided above fits nicely in that estimated calorie range . Following surgery a woman of
N.G.s stature is recommended to consume 66 83 grams of protein . This range is
slightly higher than for the average person due to the increased need of nutrients for
healing.
Current prescribed diet
N.G. was discharged to home on a soft food, fork tender diet . She will be able to
advance to solid food as tolerated.
State rationale for the diet and any diet changes while in hospital
The diet orders prescribed were appropriate for N .G. as she was working on
advancing her diet. She was NPO prior to surgery and directly following surgery. When
she was awake and alert N.G. was advanced to a clear liquid diet. On the clear liquid
diet she could have broth, juice, clear soda, and Jell-O . When the patient demonstrated
tolerance of clear liquids, her diet was progressed to a full liquid diet . She maintained
this diet order until she was able to pass gas and have a bowel movement (BM) .

Following the gas and BM she was put on a soft foods, fork tender diet . This is the diet
she was discharged home on and the patient was provided instructions on how to
progress.
The patient was frustrated with the rate of progression regarding her diet after
surgery. It was explained to the patient that her GI tract needed time to heal . The
stepwise progression was necessary to ease her body back into normal digestion and
absorption of food and beverages.
Patients physical and psychological response to diet
Although the patient was frustrated with the rate of progression of her diet, her
body tolerated the progression well . She had slight nausea following surgery, but never
vomited. She was able to tolerate each diet order as it progressed up the ladder . Her
physical response to the diet could not have gone smoother .
List nutrition related problems with supporting evidence
Unintentional weight loss possible malabsorption in the large intestine,
decreased appetite
Diarrhea malabsorption in the large intestine
Anemia inadequate PO, slight malabsorption in the large intestine
s/p surgery
Ileus altered intestinal equilibrium, resulting in paralysis of intestinal segments
o Resolved shortly after patient began taking walks
Evaluation of present nutritional status
Upon discharge N.G. appeared stable and adequately nourished . Her labs were
all within normal range, or trending in the right direction . N.G. was beginning to eat well,
per nursing documentation and tolerated the soft diet prior to discharge . She was very
anxious to eat a normal diet, and I have no doubt she ate better after discharge . Cutting
back on her daily fat intake will be beneficial for her health as well as incorporating
exercise into her daily routine.
Consideration of vitamin/mineral supplements
One of the main functions of the large intestine is the reabsorption of water and
electrolytes. Following a R. Hemicolectomy procedure may result in the loss of fluid and
electrolytes that normally would be reabsorbed . As the intestines heal they adapt to the
new structure and attempt to compensate for the missing colon . Studies done on
patients receiving colectomies show up to 500 milliliters of fluid and electrolytes can be
excreted. The loss of such fluid and electrolytes can affect a patients hydration and acid
base balance. Adequate fluid intake is highly necessary for N .G. to stay hydrated as

well as B12 supplementation and adequate sodium intake.

Prognosis:
Patient N.G. has a very optimal prognosis. Upon discharge she was tolerating
her soft, fork tender food diet. This provides evidence that her digestive system was

functioning properly. She was taking daily walks, passing gas and had bowel
movements. N.G. will need to continue getting checked for polyps as the recurrence is
elevated, but she is expected to have a full recovery. N.G. should gain back the weight
she lost prior to surgery and any weight she lost while at the hospital . Due to her
dissatisfaction with the liquid diet, she may have lost a couple of pounds following
surgery.
It is possible N.G. may experience impaired continence after her colon resection .
In a study done on patients with colectomies, 92% of them leaked stools in their sleep,
while none of them experienced leaking during the day. The study was able to conclude
that colectomy surgery preserves the anal sphincter, but decreases the capacity and
compliance of the colon. As N.G. advances to a solid diet she is at risk for experiencing
the inability to control her bowels throughout the night .5,6

Summary and conclusion:

N.G. scheduled a routine colonoscopy, which turned into her receiving a colon
resection from a mass found in her ceacum . N.G. was experiencing unintended weight
loss as well as unexplained diarrhea prior to her colon resection . Now that she has had
the mass removed I would expect her to have no problem recovering and gaining back
her lost weight. She is currently at a healthy weight so even maintaining her weight
would be appropriate. N.G. was an opinionated, determined 78-year-old woman and I
am confident she will go right back to the life she was living before she had surgery .
I was able to check on N.G. daily after she finished her surgery. I was able to
provide her support and encouragement regarding oral intake . Because N.G. was not
thrilled with her liquid diet orders following surgery, she required coaxing and
encouragement to order meals and eat them . Until the weekend approached I was able
to check in on N.G. daily to make sure she had ordered meals and eaten the food on
the tray.
This patient and I formed a nice bond the first time I met her . She seemed rather
lonely in her hospital room and her face would light up when I came in to check on her .
She would chat and ask me about my life and tell me about her granddaughter . Through
this connection made, she formed a level of trust in what I said and asked of her . She
would order meals when I would come check on her or if she had an untouched tray in
her room when I stopped in she would begin eating it . N.G. taught me the importance of
rapport.
I also learned more about the large intestine and its specific functions . I learned
about the secretions and absorption abilities of the large intestine and I learned more
about colectomies. The R. Hemicolectomy that N.G. had done was something I had
never heard of prior to my case study project. I am glad I was able to learn so much and
I know that the knowledge I learned will stick with my through my professional career .

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