Susanne Wood, RGN, DipN, formerly nutrition nurse specialist, Kingston Hospital, Surrey, now retired; updated by Lynne Colagiovanni, RN, BSc, consultant nurse - nutrition support, University Hospital Birmingham NHS Foundation Trust
The gastrointestinal tract is the route for the entry of fluids and nutrients into the body. Diseases of the system, or conditions of other organs which cause gastro intestinal symptoms, are likely to effect nutritional status through impairing function in a number of ways listed in Table 1.
Table 1. Gastrointestinal disorders
|Ingestion||Anorexia, nausea, vomiting, sore mouth, dysphagia, poor dentition, anxiety, depression, pain, changes in taste perception. Therapeutic or self-imposed dietary changes|
|Digestion||Reduction in digestive secretions – gastric acid, bile salts, pancreatic and small bowel enzymes|
|Absorption||Disorders of motility for example, ileus, reduced absorptive surface due to extensive disease or resection, increased small bowel transit times, villous atrophy, drugs, small bowel bacterial overgrowth.|
|Increased nutritional losses||Vomiting, nasogastric aspiration, diarrhoea, wound drainage, fistula, haemorrhage, ascites, high stoma output.|
|Increased requirements||Inflammation and infection, malignant disease, growth (in children and young people).|
Key aspects of assessment
In addition to the general nutritional assessment measures, described elsewhere in this section, the following are particularly important for patients with gastrointestinal disease.
History of dietary changes
Patients with gastrointestinal disease often modify the diet in order to relieve symptoms and this information can help identify the diagnosis. Self imposed dietary changes, or those recommended by individuals without sufficient knowledge of the disease process, have the potential for causing nutritional deficiencies. The nurse, working with the dietitian, needs sensitivity when discussing these issues to prevent the patient feeling criticised.
Observation of the frequency, volume and nature of gastrointestinal losses
This helps to monitor response to therapy and again is important for indicating specific deficiencies (Box 1).
Box 1. The sodium and potassium content of gastrointestinal fluids
Nutritional care in gastrointestinal disease
Restoring or maintaining a good nutritional status
Interventions performed to treat a disease or relieve symptoms must not put patients’ general nutritional status at risk
Collaborative working between nurses, doctors, dietitians and pharmacists is beneficial as each brings their experience, skill and body of knowledge to the problem. Nurses must not assume that members of other disciplines are aware of problems such as reduced nutritional intake, muscle loss, poor stamina, slow wound healing that are only evident during the delivery of nursing care. Good lines of communication are crucial between team members.
If food intake is low, do not attempt to reduce the fat content of the diet (unless there is a therapeutic requirement to do so). Fats are energy dense, containing approximately twice as many kcal per gram as carbohydrate or protein. They are also responsible for much of the flavour in food. Alcohol also stimulates the appetite but contributes to gastro-oesophageal reflux and gastritis and should be omitted from the diet completely in patients with pancreatic and liver disease.
An upright posture should be maintained during and for a period immediately following the meal if a patient has gastro-oesophageal reflux disease. Large meals should be avoided.
When the colon is inflamed and sensitive, for example due to ulcerative colitis, Crohn’s disease or radiotherapy, the gastrocolic reflex initiated by food entering the stomach may cause the meal to be halted suddenly by diarrhoea and abdominal pain. Following rest and recovery the patient should be offered a snack or liquid food supplement to compensate for the food that has been missed. This principle should also be followed for any other patients failing to eat sufficient food.
Control of symptoms
Dietary fibre plays an important role in reducing the risk of colorectal cancer. Increased amounts are often recommended to aid the control of bowel function for example, in irritable bowel disease. The resulting wind may increase pain or social discomfort. It is important to aim for an intake that produces tolerable symptoms.
Replacement of nutrients
The colon is the principal site of salt absorption. Salt should be added to cooking and used at the table if a patient has an ileostomy. In the case of high ileostomy losses, or excessive diarrhoea via an intact colon when food intake may be low, additional sodium may need to be provided as an oral rehydration solution such as Dioralyte.
Vitamin B is replaced by injection every three months when absorption is prevented by absence of gastric acid, gastric resection or disease of the terminal metre of ileum.
Fluid losses from wounds, entero-cutaneous fistula and diarrhoea contains protein, iron, zinc, water and electrolytes. Replacement of these either orally, enterally or parenterally may be required.
If food intake is insufficient to meet nutritional requirements a nutritional supplement may be offered. If intake is still insufficient an enteral tube feed may be neededrequired. Dependng on the type and amount of enteral feed tolerated a vitamin and trace element supplement may be required.
Parenteral nutrition is only administered if small bowel absorption is inadequate or there is a requirement to rest the intestine.
Aspinal, R.J., Taylor-Robinson, S.D. (2002) Color Atlas and Text of Gastroenterology and Liver Disease. St Louis: Mosby.